Provider Demographics
NPI:1962576033
Name:MAGDALA FOUNDATION
Entity type:Organization
Organization Name:MAGDALA FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGOGNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-652-6004
Mailing Address - Street 1:4158 LINDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2914
Mailing Address - Country:US
Mailing Address - Phone:314-652-6004
Mailing Address - Fax:314-652-8351
Practice Address - Street 1:3148 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1118
Practice Address - Country:US
Practice Address - Phone:314-571-9950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
MO2452-10039315P00000X
MO2452-10040315P00000X
MO2452-10041315P00000X
MO2452-10042315P00000X
MO2452, 1460-7235320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO852098805Medicaid
MO112364401Medicaid
MO112364500Medicaid
MO112182704Medicaid
MO112182605Medicaid