Healthcare Provider Details

I. General information

NPI: 1578899852
Provider Name (Legal Business Name): ULTIMATE CARE ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2009
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 N KINGSHIGHWAY BLVD
SAINT LOUIS MO
63115-1618
US

IV. Provider business mailing address

2905 N KINGSHIGHWAY BLVD
SAINT LOUIS MO
63115-1618
US

V. Phone/Fax

Practice location:
  • Phone: 314-802-7126
  • Fax:
Mailing address:
  • Phone: 314-802-7126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberLC0994486
License Number StateMO

VIII. Authorized Official

Name: BRENDA S AYUSO
Title or Position: MANAGER
Credential:
Phone: 314-802-7126