Healthcare Provider Details

I. General information

NPI: 1548748148
Provider Name (Legal Business Name): AMAZING TIMES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9921 HOLTWICK AVE
ST ANN MO
63074
US

IV. Provider business mailing address

800 N TUCKER BLVD STE 454
SAINT LOUIS MO
63101-1000
US

V. Phone/Fax

Practice location:
  • Phone: 314-283-0139
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. HENRIETTA Y GLADNEY
Title or Position: MEMBER
Credential:
Phone: 314-283-0139