Healthcare Provider Details

I. General information

NPI: 1356462493
Provider Name (Legal Business Name): ST. JOHN'S MERCY CHILD DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 N NEW BALLAS RD
SAINT LOUIS MO
63141-6713
US

IV. Provider business mailing address

641 N NEW BALLAS RD
SAINT LOUIS MO
63141-6713
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-3345
  • Fax: 314-872-3180
Mailing address:
  • Phone: 314-872-3345
  • Fax: 314-872-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number2003016370
License Number StateMO

VIII. Authorized Official

Name: MIRIAM HELENE RUPP
Title or Position: PHYSICAL THERAPIST
Credential: P.T.
Phone: 314-872-3345