Healthcare Provider Details

I. General information

NPI: 1215936588
Provider Name (Legal Business Name): AGING WELL HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 BALSON AVE
SAINT LOUIS MO
63130-3001
US

IV. Provider business mailing address

7212 BALSON AVE
SAINT LOUIS MO
63130-3001
US

V. Phone/Fax

Practice location:
  • Phone: 314-726-5600
  • Fax: 314-754-9317
Mailing address:
  • Phone: 314-726-5600
  • Fax: 314-754-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number609
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number266633
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1010588
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number265855403
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number285855409
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number266633
License Number StateMO
# 7
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number755
License Number StateMO

VIII. Authorized Official

Name: IRINA BURSAK
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-726-5600