=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346695582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCCLAY ADULT DAY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2016
-----------------------------------------------------
Last Update Date | 04/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3821 MCCLAY RD
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-7327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-922-9595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3821 MCCLAY RD
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-7327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-922-9595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO OWNER
-----------------------------------------------------
Name | MRS. JENNIFER GETTMAN
-----------------------------------------------------
Credential | MA, CEO, NHA
-----------------------------------------------------
Telephone | 636-219-3114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 1323
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------