=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760156913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN FAMILY ADULT DAYCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2021
-----------------------------------------------------
Last Update Date | 08/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11763 BENHAM RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63136-6113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-308-9106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11763 BENHAM RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63136-6113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-308-9106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KIMBERLY ETIS NORTHERN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-308-9106
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------