Healthcare Provider Details

I. General information

NPI: 1649453796
Provider Name (Legal Business Name): SOUTHSIDE WELLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 PARK AVE
SAINT LOUIS MO
63104-1433
US

IV. Provider business mailing address

3017 PARK AVE
SAINT LOUIS MO
63104-1433
US

V. Phone/Fax

Practice location:
  • Phone: 314-664-5024
  • Fax:
Mailing address:
  • Phone: 314-664-5024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number291705606
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number281705608
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number851705608
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number261705602
License Number StateMO

VIII. Authorized Official

Name: MARY PARRAM
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 314-664-5024