Healthcare Provider Details

I. General information

NPI: 1710369608
Provider Name (Legal Business Name): FRESH START ADULT DAY CARE OF MISSOURI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111-113 ST MAIN
WINDSOR MO
65360
US

IV. Provider business mailing address

2700 LACEWOOD DR
COLUMBIA MO
65201-3545
US

V. Phone/Fax

Practice location:
  • Phone: 660-647-0207
  • Fax:
Mailing address:
  • Phone: 573-289-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1247
License Number StateMO

VIII. Authorized Official

Name: KALEEM UDDIN SYED
Title or Position: PRESIDENT/CEO
Credential: M.D
Phone: 573-289-7500