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General NPI Number Information
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NPI Number | 1487995254
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Entity Type | Organization
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Legal Business Name | IVY TERRACE AT GAMBRILL GARDENS III
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Dates
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Enumeration Date | 03/04/2013
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Last Update Date | 03/04/2013
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Provider Practice Location Address
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Address Line | 1 STRECKER RD
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City | ELLISVILLE
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State | MO
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Zip | 63011-1998
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Country | US
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Telephone | 636-394-2992
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Fax |
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Provider Business Mailing Address
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Address Line | 1 STRECKER RD
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City | ELLISVILLE
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State | MO
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Zip | 63011-1998
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Country | US
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Telephone | 636-394-2992
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. MARY JANE HARRIS
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Credential | MSW, NHA
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Telephone | 636-394-2992
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 040294
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License Number State | MO
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