Healthcare Provider Details

I. General information

NPI: 1194456749
Provider Name (Legal Business Name): PASSION ADULT DAYCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/23/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4068 MAFFITT AVE
SAINT LOUIS MO
63113-3235
US

IV. Provider business mailing address

4068 MAFFITT AVE
SAINT LOUIS MO
63113-3235
US

V. Phone/Fax

Practice location:
  • Phone: 314-933-0155
  • Fax:
Mailing address:
  • Phone: 314-933-0155
  • 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: LANISHA MARTIN
Title or Position: OWNER
Credential:
Phone: 314-933-0155