Healthcare Provider Details

I. General information

NPI: 1356341077
Provider Name (Legal Business Name): MARY QUEEN AND MOTHER ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 WATSON RD
SAINT LOUIS MO
63119-5001
US

IV. Provider business mailing address

7601 WATSON RD
SAINT LOUIS MO
63119-5001
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-8000
  • Fax: 314-961-3580
Mailing address:
  • Phone: 314-961-8000
  • Fax: 314-961-3580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030630
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. KAREN M. LEDBETTER
Title or Position: ADMINISTRATOR
Credential: CNHA
Phone: 314-961-8000