Healthcare Provider Details

I. General information

NPI: 1336661719
Provider Name (Legal Business Name): HOUSE OF DESTINY ADULT DAY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4507 OLIVE STREET
ST LOUIS MO
63108
US

IV. Provider business mailing address

4507 OLIVE ST
SAINT LOUIS MO
63108-1814
US

V. Phone/Fax

Practice location:
  • Phone: 314-669-1755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1428
License Number StateMO

VIII. Authorized Official

Name: MICHELLE TERRY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-669-1755