Healthcare Provider Details

I. General information

NPI: 1477831576
Provider Name (Legal Business Name): THE KING'S OUTREACH MINISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 OLIVE BLVD
SAINT LOUIS MO
63130-1701
US

IV. Provider business mailing address

7330 OLIVE BLVD
SAINT LOUIS MO
63130-1701
US

V. Phone/Fax

Practice location:
  • Phone: 314-725-8116
  • Fax: 314-727-7015
Mailing address:
  • Phone: 314-725-8116
  • Fax: 314-727-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number960
License Number StateMO

VIII. Authorized Official

Name: MRS. CAROL MITCHELL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-727-7015