Healthcare Provider Details

I. General information

NPI: 1093514200
Provider Name (Legal Business Name): ADVANCE WELLNESS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7915 OLIVE BLVD
SAINT LOUIS MO
63130-2020
US

IV. Provider business mailing address

7915 OLIVE BLVD
SAINT LOUIS MO
63130-2020
US

V. Phone/Fax

Practice location:
  • Phone: 314-665-9134
  • Fax: 314-453-3897
Mailing address:
  • Phone: 314-665-9134
  • Fax: 314-453-3897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. EBONY S HAGENS
Title or Position: OWNER
Credential:
Phone: 314-665-9134