MEDICARE: PROCARE ISL, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1598323115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROCARE ISL, LLC

Provider Business Mailing Address
First Line	:	2040 WOODSON RD STE 203B
Second Line	:
City	:	OVERLAND
State	:	MO
Zip	:	63114-5606
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2040 WOODSON RD STE 203B
Second Line	:
City	:	OVERLAND
State	:	MO
Zip	:	63114-5606
Country	:	US
Telephone Number	:	314-755-1444
Fax Number	:	314-755-1446

Authorized Official
Title or Position	:	OWNER
Name	:	TIGRE SMITH
Credential	:
Telephone Number	:	314-757-0188

Provider Enumeration Date	:	05/29/2019
Last Update Date	:	05/29/2019

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Directions to “PROCARE ISL, LLC ” Practice Location

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