Provider Demographics
NPI:1992102438
Name:BRYANT'S & KING'S ASSISTED LIVING
Entity type:Organization
Organization Name:BRYANT'S & KING'S ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:EMONA
Authorized Official - Middle Name:LASHELLE
Authorized Official - Last Name:EWHAREKUKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-526-1352
Mailing Address - Street 1:2162 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MO
Mailing Address - Zip Code:63121
Mailing Address - Country:US
Mailing Address - Phone:314-526-1352
Mailing Address - Fax:
Practice Address - Street 1:2162 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-5625
Practice Address - Country:US
Practice Address - Phone:314-526-1352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOS137338040251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
47-1693183OtherBLUE CROSS, BLUE SHIELD, ATENA,KAISER-PERMANENTE
MO47-1693183OtherBLUE CROSS, BLUE SHIELD, ATENA,KAISER-PERMANENTE