Healthcare Provider Details

I. General information

NPI: 1235397704
Provider Name (Legal Business Name): GENESIS ADULT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 OLIVE BLVD
SAINT LOUIS MO
63132-2815
US

IV. Provider business mailing address

8405 OLIVE BLVD
SAINT LOUIS MO
63132-2815
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-1002
  • Fax:
Mailing address:
  • Phone: 314-989-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number763
License Number StateMO

VIII. Authorized Official

Name: JUNE WALKER
Title or Position: OWNER
Credential:
Phone: 314-989-1002