MEDICARE: THE SALVATION ARMY MIDLAND DIVISION

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1184898272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SALVATION ARMY MIDLAND DIVISION

Provider Business Mailing Address
First Line	:	1130 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-3147
Country	:	US
Telephone Number	:	314-646-3000
Fax Number	:	314-646-3201

Provider Business Practice Location Address
First Line	:	3010 WASHINGTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-1335
Country	:	US
Telephone Number	:	314-652-1310
Fax Number	:	314-286-3230

Authorized Official
Title or Position	:	DIVISIONAL COMMANDER
Name	:	LONNEAL RICHARDSON, MAJOR
Credential	:
Telephone Number	:	314-646-3000

Provider Enumeration Date	:	04/18/2008
Last Update Date	:	04/18/2008

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