=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992112916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMBRIDGE ADULT DAY - ST. CHARLES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2014
-----------------------------------------------------
Last Update Date | 07/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2061 EXCHANGE DR
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-5987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-757-3672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2061 EXCHANGE DR
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-5987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-757-3672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | KELLE WAHOFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-434-2769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 1194
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------