Healthcare Provider Details

I. General information

NPI: 1760156913
Provider Name (Legal Business Name): NORTHERN FAMILY ADULT DAYCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11763 BENHAM RD
SAINT LOUIS MO
63136-6113
US

IV. Provider business mailing address

11763 BENHAM RD
SAINT LOUIS MO
63136-6113
US

V. Phone/Fax

Practice location:
  • Phone: 314-308-9106
  • Fax:
Mailing address:
  • Phone: 314-308-9106
  • 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: KIMBERLY ETIS NORTHERN
Title or Position: DIRECTOR
Credential:
Phone: 314-308-9106