Healthcare Provider Details

I. General information

NPI: 1174669006
Provider Name (Legal Business Name): INDEPENDENCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2443 PROUHET AVE
SAINT LOUIS MO
63114-1946
US

IV. Provider business mailing address

8675 OLIVE BLVD
SAINT LOUIS MO
63132-2503
US

V. Phone/Fax

Practice location:
  • Phone: 314-890-7100
  • Fax: 314-890-7133
Mailing address:
  • Phone: 314-373-5187
  • Fax: 314-367-5626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number030777
License Number StateMO

VIII. Authorized Official

Name: MRS. PATRICIA HOLMES
Title or Position: EXECTUVE DIRECTOR
Credential:
Phone: 314-880-5415