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General NPI Number Information
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NPI Number | 1376092445
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Entity Type | Organization
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Legal Business Name | GRACE CONSUMER DIRECTED SERVICES LLC
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Dates
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Enumeration Date | 09/29/2016
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Last Update Date | 09/29/2016
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Provider Practice Location Address
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Address Line | 1600 HERITAGE LNDG STE 202A
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City | SAINT PETERS
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State | MO
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Zip | 63303-8488
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Country | US
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Telephone | 314-552-1604
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Fax |
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Provider Business Mailing Address
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Address Line | 1600 HERITAGE LNDG STE 202A
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City | SAINT PETERS
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State | MO
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Zip | 63303-8488
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Country | US
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Telephone | 314-552-1604
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MISS JOY KATINA BLAIR
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Credential |
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Telephone | 314-552-1604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State | MO
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