Healthcare Provider Details

I. General information

NPI: 1619135985
Provider Name (Legal Business Name): MAGDALA FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 AUGUSTA AVE
SAINT LOUIS MO
63121-4802
US

IV. Provider business mailing address

4158 LINDELL BLVD
SAINT LOUIS MO
63108-2914
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number2452 10039
License Number StateMO

VIII. Authorized Official

Name: MR. DAVID JOHN MEYER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-652-6004