Healthcare Provider Details

I. General information

NPI: 1104770841
Provider Name (Legal Business Name): 4TH GENERATION ADULT DAY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2026
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 GOODFELLOW BLVD
SAINT LOUIS MO
63147-1446
US

IV. Provider business mailing address

8700 GOODFELLOW BLVD
SAINT LOUIS MO
63147-1446
US

V. Phone/Fax

Practice location:
  • Phone: 314-473-1118
  • Fax:
Mailing address:
  • Phone:
  • 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: BARRY D MOORE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-473-1118