=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295105054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUTHFUL YOU ADULT DAYCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2015
-----------------------------------------------------
Last Update Date | 10/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6363 NATURAL BRIDGE
-----------------------------------------------------
City | PINELAWN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-629-7876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5199 LONGHORN TRAIL
-----------------------------------------------------
City | FLORISSANT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-629-7876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. YOLANDA PHILLIPS
-----------------------------------------------------
Credential | NURSE
-----------------------------------------------------
Telephone | 314-629-7876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------