Healthcare Provider Details

I. General information

NPI: 1245973379
Provider Name (Legal Business Name): CIRCLE OF LIGHT ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2022
Last Update Date: 04/17/2022
Certification Date: 04/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8757 ANNETTA AVE
SAINT LOUIS MO
63147-1602
US

IV. Provider business mailing address

552 KIMBERLY LN
SAINT PETERS MO
63376
US

V. Phone/Fax

Practice location:
  • Phone: 314-723-4652
  • Fax:
Mailing address:
  • Phone: 314-723-4652
  • 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: CLAUDIA M JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 314-723-4652