1639854318 NPI number — LIVING LIFE LONG RESIDENTIAL CARE

Table of content: (NPI 1639854318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639854318 NPI number — LIVING LIFE LONG RESIDENTIAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING LIFE LONG RESIDENTIAL CARE
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:
1639854318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 UNION BLVD STE 300
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:
63108-4402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-495-5498
Provider Business Mailing Address Fax Number:
866-883-0221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5076 WATERMAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63108-1102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-495-5498
Provider Business Practice Location Address Fax Number:
866-883-0221
Provider Enumeration Date:
06/20/2023

Additional Information

Authorized Official

Authorized Official Last Name:
BEATTY
Authorized Official First Name:
SHERRONE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
314-497-5284

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3104A0625X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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