Healthcare Provider Details

I. General information

NPI: 1003083155
Provider Name (Legal Business Name): CHEROKEE RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 MISSOURI AVE
SAINT LOUIS MO
63118
US

IV. Provider business mailing address

3409 MISSOURI AVE
SAINT LOUIS MO
63118
US

V. Phone/Fax

Practice location:
  • Phone: 314-368-3247
  • Fax: 314-771-1377
Mailing address:
  • Phone: 314-368-3247
  • Fax: 314-771-1377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number034514
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number042586
License Number StateMO

VIII. Authorized Official

Name: MR. GREGORY RANDAL GETTMAN
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 314-368-3247