=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134554181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOGI ADULT DAY CARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2013
-----------------------------------------------------
Last Update Date | 09/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4365 CHIPPEWA ST SUITE 102
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63116-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-696-2510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4365 CHIPPEWA ST SUITE 102
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63116-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-696-2510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MR. EDIN HALILOVIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-696-2510
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 1128
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------