Healthcare Provider Details

I. General information

NPI: 1386999324
Provider Name (Legal Business Name): FAMILY LOVE ADULT HEALTH CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 DEBALIVIERE AVENUE
ST. LOUIS MO
63112
US

IV. Provider business mailing address

865 CHARLESGATE DRIVE
ST. LOUIS MO
63132
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-3458
  • Fax:
Mailing address:
  • Phone: 314-432-7727
  • 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: JOYCE MARIE WILKS
Title or Position: OWNER
Credential:
Phone: 314-432-7727