MEDICARE: ULTIMATE CARE ADULT DAY CARE SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1073149290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTIMATE CARE ADULT DAY CARE SERVICES LLC

Provider Business Mailing Address
First Line	:	1322 LEROY AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63133-1504
Country	:	US
Telephone Number	:	314-600-8879
Fax Number	:

Provider Business Practice Location Address
First Line	:	1322 LEROY AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63133-1504
Country	:	US
Telephone Number	:	314-600-8879
Fax Number	:	314-228-2005

Authorized Official
Title or Position	:	OWNER
Name	:	TERRIKAH COOK
Credential	:
Telephone Number	:	314-600-8879

Provider Enumeration Date	:	03/19/2020
Last Update Date	:	02/16/2023

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