1053796219 NPI number — MARDRAS MARVELOUS MISSION I LLC

Table of content: (NPI 1053796219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053796219 NPI number — MARDRAS MARVELOUS MISSION I LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARDRAS MARVELOUS MISSION I LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053796219
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3830 WASHINGTON BLVD
Provider Second Line Business Mailing Address:
STE 109
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63108-3460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-465-3004
Provider Business Mailing Address Fax Number:
314-833-3170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3830 WASHINGTON BLVD
Provider Second Line Business Practice Location Address:
STE 109
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63108-3460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-659-9090
Provider Business Practice Location Address Fax Number:
314-833-3170
Provider Enumeration Date:
07/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SHELTON
Authorized Official First Name:
SHAUNICE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
314-659-9090

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DHSS , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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