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NPI Code Detail

MEDICARE: JUDEVINE, INC.

MEDICARE: JUDEVINE, INC.
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
1251C00000XDevelopmentally Disabled Services Day Training Agency
2251S00000XCommunity/Behavioral Health AgencyER019910064MO
3252Y00000XEarly Intervention Provider Agency
4253Z00000XIn Home Supportive Care Agency
5320900000XIntellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityER019910064MO

General Provider Information

NPI Number : 1518291418
Entity Type Code : Organization
Provider Name (Legal Business Name) : JUDEVINE, INC.
Provider Business Mailing Address
First Line : 1810 CRAIG RD STE 109
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63146-4758
Country : US
Telephone Number : 800-780-6545
Fax Number : 888-507-4453
Provider Business Practice Location Address
First Line : 1810 CRAIG RD STE 109
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63146-4758
Country : US
Telephone Number : 800-780-6545
Fax Number : 888-507-4453
Authorized Official
Title or Position : PRESIDENT/DIRECTOR
Name : MS. REBECCA BLACKWELL
Credential : MA, BCBA
Telephone Number : 800-780-6545
Provider Enumeration Date : 09/24/2009
Last Update Date : 01/07/2015

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