Healthcare Provider Details

I. General information

NPI: 1962576033
Provider Name (Legal Business Name): MAGDALA FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3148 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63139-1118
US

IV. Provider business mailing address

4158 LINDELL BLVD
SAINT LOUIS MO
63108-2914
US

V. Phone/Fax

Practice location:
  • Phone: 314-571-9950
  • Fax:
Mailing address:
  • Phone: 314-652-6004
  • Fax: 314-652-8351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number2452-10039
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number2452-10040
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number2452-10041
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2452, 1460-7235
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number2452-10042
License Number StateMO

VIII. Authorized Official

Name: THOMAS MANGOGNA
Title or Position: PRESIDENT/CEO
Credential:
Phone: 314-652-6004