=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134955024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENTLE HEARTS ADULT DAY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2024
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 826 UNION BLVD STE L109
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108-1040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-701-8131
-----------------------------------------------------
Fax | 314-782-3455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 826 UNION BLVD STE L113
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108-1040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-701-8131
-----------------------------------------------------
Fax | 314-782-3455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | ALISSHA RENEE MITCHELL- JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-701-8131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------