1013046937 NPI number — ST. ELIZABETH ADULT DAY CARE CENTER, INC.

Table of content: DEBRA MAHON MSW, LSW (NPI 1598131781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013046937 NPI number — ST. ELIZABETH ADULT DAY CARE CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. ELIZABETH ADULT DAY CARE CENTER, INC.
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:
6
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:
1013046937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3401 ARSENAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63118-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-772-5107
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2142 SWITZER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JENNINGS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63136-3842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-867-6511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
ANTONIO
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
314-772-5107

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , with the licence number:  578 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0002044 . This is a "SSBG ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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