Healthcare Provider Details

I. General information

NPI: 1073349577
Provider Name (Legal Business Name): MILITIA OF GRACE ADULT CARE CENTER 'LLC'
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4266 E NATURAL BRIDGE AVE
SAINT LOUIS MO
63115-3311
US

IV. Provider business mailing address

4266 E NATURAL BRIDGE AVE
SAINT LOUIS MO
63115-3311
US

V. Phone/Fax

Practice location:
  • Phone: 314-828-0804
  • Fax:
Mailing address:
  • Phone: 314-828-0804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BJ T. BUCHANNON
Title or Position: CEO/OWNER
Credential:
Phone: 314-828-0804