=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972900918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERRI'S ADULT DAY CARE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2014
-----------------------------------------------------
Last Update Date | 11/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12444 LUSHER RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63138-1456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-738-9690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12444 LUSHER RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63138-1456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-738-9690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MS. ANETTA BOLDEN-ROBERTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-413-3862
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1215
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------