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NPI Code Detail

MEDICARE: ST. ELIZABETH ADULT DAY CARE CENTER INC

MEDICARE: ST. ELIZABETH ADULT DAY CARE CENTER 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
1311ZA0620XAdult Care Home Facility1076MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11013046937OTHERMONPI
21619006467OTHERMONPI
31184740847OTHERMONPI
41407986847OTHERMONPI
51801925664OTHERMONPI
61487783254OTHERMONPI
71730218660OTHERMONPI

General Provider Information

NPI Number : 1871831339
Entity Type Code : Organization
Provider Name (Legal Business Name) : ST. ELIZABETH ADULT DAY CARE CENTER INC
Provider Business Mailing Address
First Line : 3683 COOK AVE
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63113-3831
Country : US
Telephone Number : 314-772-5107
Fax Number : 314-772-3674
Provider Business Practice Location Address
First Line : 1424 S 1ST CAPITOL DR
Second Line :
City : SAINT CHARLES
State : MO
Zip : 63303-3702
Country : US
Telephone Number : 636-724-2110
Fax Number : 636-724-2110
Authorized Official
Title or Position : ADMINISTRATOR
Name : JOHN ANTONIO MILLER
Credential : CPPS
Telephone Number : 314-772-5107
Provider Enumeration Date : 01/17/2013
Last Update Date : 01/17/2013

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