Healthcare Provider Details

I. General information

NPI: 1861665846
Provider Name (Legal Business Name): MCCB TRANSITIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 SAINT LOUIS AVE
SAINT LOUIS MO
63115-3218
US

IV. Provider business mailing address

4110 SAINT LOUIS AVE
SAINT LOUIS MO
63115-3218
US

V. Phone/Fax

Practice location:
  • Phone: 314-371-1657
  • Fax: 314-371-4333
Mailing address:
  • Phone: 314-371-1657
  • Fax: 314-371-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberERO19908010
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberERO19908010
License Number StateMO

VIII. Authorized Official

Name: MS. MARY L BARFIELD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-371-1657