Healthcare Provider Details

I. General information

NPI: 1053796219
Provider Name (Legal Business Name): MARDRAS MARVELOUS MISSION I LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 WASHINGTON BLVD STE 109
SAINT LOUIS MO
63108-3460
US

IV. Provider business mailing address

3830 WASHINGTON BLVD STE 109
SAINT LOUIS MO
63108-3460
US

V. Phone/Fax

Practice location:
  • Phone: 314-659-9090
  • Fax: 314-833-3170
Mailing address:
  • Phone: 636-465-3004
  • Fax: 314-833-3170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SHAUNICE SHELTON
Title or Position: EXECUTIVE DIRECTOR
Credential: BSN RN
Phone: 314-659-9090