Provider Demographics
NPI:1073771358
Name:MAGDALA FOUNDATION
Entity Type:Organization
Organization Name:MAGDALA FOUNDATION
Other - Org Name:MAURY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYER
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 1:3117 MAURY AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-2021
Practice Address - Country:US
Practice Address - Phone:314-652-6004
Practice Address - Fax:314-652-8351
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGDALA FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2452 10041315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO112364500Medicaid