Healthcare Provider Details

I. General information

NPI: 1518291418
Provider Name (Legal Business Name): JUDEVINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 CRAIG RD STE 109
SAINT LOUIS MO
63146-4758
US

IV. Provider business mailing address

1810 CRAIG RD STE 109
SAINT LOUIS MO
63146-4758
US

V. Phone/Fax

Practice location:
  • Phone: 800-780-6545
  • Fax: 888-507-4453
Mailing address:
  • Phone: 800-780-6545
  • Fax: 888-507-4453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberER019910064
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberER019910064
License Number StateMO

VIII. Authorized Official

Name: MS. REBECCA BLACKWELL
Title or Position: PRESIDENT/DIRECTOR
Credential: MA, BCBA
Phone: 800-780-6545