Provider Demographics
NPI:1487783254
Name:ST ELIZABETH ADULT DAY CARE CENTER
Entity type:Organization
Organization Name:ST ELIZABETH ADULT DAY CARE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:CPPS
Authorized Official - Phone:314-772-5107
Mailing Address - Street 1:3401 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-2001
Mailing Address - Country:US
Mailing Address - Phone:314-772-5107
Mailing Address - Fax:
Practice Address - Street 1:317 HOFFMEISTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-1609
Practice Address - Country:US
Practice Address - Phone:314-638-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO627261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0008593OtherSSBG ID