Provider Demographics
NPI:1215936588
Name:AGING WELL HEALTH CARE, LLC
Entity type:Organization
Organization Name:AGING WELL HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURSAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-726-5600
Mailing Address - Street 1:7212 BALSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3001
Mailing Address - Country:US
Mailing Address - Phone:314-726-5600
Mailing Address - Fax:314-754-9317
Practice Address - Street 1:7212 BALSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-3001
Practice Address - Country:US
Practice Address - Phone:314-726-5600
Practice Address - Fax:314-754-9317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO755251E00000X
IL1010588251E00000X
MO265855403251J00000X
MO609261QA0600X
MO266633261QP2000X, 261QX0100X
MO285855409385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO295855407Medicaid
MO575855408Medicaid
MO585855406Medicaid
MO285855409Medicaid
MO265855403Medicaid
MO295855407Medicaid
MO285855409Medicaid