Healthcare Provider Details

I. General information

NPI: 1508235680
Provider Name (Legal Business Name): PAULINE'S PLACE ADULT DAY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8460 WATSON RD 130
SAINT LOUIS MO
63119-5247
US

IV. Provider business mailing address

8460 WATSON RD 130
SAINT LOUIS MO
63119-5247
US

V. Phone/Fax

Practice location:
  • Phone: 314-438-7100
  • Fax:
Mailing address:
  • Phone: 314-438-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1266
License Number StateMO

VIII. Authorized Official

Name: BETTY JONES
Title or Position: PROGRAM MANAGER
Credential:
Phone: 314-438-7100