Provider Demographics
NPI:1104473750
Name:HEALING WATERS OF ST LOUIS LLC
Entity type:Organization
Organization Name:HEALING WATERS OF ST LOUIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-397-6197
Mailing Address - Street 1:1670 HORSESHOE DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-2526
Mailing Address - Country:US
Mailing Address - Phone:314-397-6197
Mailing Address - Fax:
Practice Address - Street 1:1670 HORSESHOE DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-2526
Practice Address - Country:US
Practice Address - Phone:314-397-6197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty