=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598496663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE FAITH HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2022
-----------------------------------------------------
Last Update Date | 06/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 269 S BARAT AVE
-----------------------------------------------------
City | FERGUSON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63135-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-669-5389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1608 VENTNOR PL
-----------------------------------------------------
City | FLORISSANT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63031-1526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-606-0225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/OWNER
-----------------------------------------------------
Name | TAWANDA STORY
-----------------------------------------------------
Credential | LPN, LNHA,BA,MHA
-----------------------------------------------------
Telephone | 618-606-0225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------