Basic Information
| Provider Information | |||||||||
| NPI: | 1063625515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOPEWELL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 218 GREENSHIRE LN | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633688364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363797727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4411 N NEWSTEAD AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631152534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145311770 | ||||||||
| FaxNumber: | 3143816796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3145311770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 36874 | MO | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 36874 | 01 | MO | R.N. | OTHER |