Healthcare Provider Details

I. General information

NPI: 1134305485
Provider Name (Legal Business Name): ST. LOUIS ARC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 LACKLAND HILL PKWY 10130 B MANCHESTER
SAINT LOUIS MO
63146-3507
US

IV. Provider business mailing address

1816 LACKLAND HILL PKWY SUITE 200
SAINT LOUIS MO
63146-3507
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-2211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number103091
License Number StateMO

VIII. Authorized Official

Name: MRS. KATHLEEN ANNE TISONE
Title or Position: VP OF OPERATIONS/CFO
Credential:
Phone: 314-569-2211