=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952618936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENHANCED QUALITY OF LIFE LLC ADULT DAY PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2010
-----------------------------------------------------
Last Update Date | 09/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 CHEZ PAREE DR
-----------------------------------------------------
City | HAZELWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63042-3540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-610-6153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 262
-----------------------------------------------------
City | FLORISSANT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63032-0262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MR. RAYMONE WEBB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-610-6092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------