Provider Demographics
NPI:1114220779
Name:YOUNG IN SPIRIT ADULT DAYCARE, LLC
Entity Type:Organization
Organization Name:YOUNG IN SPIRIT ADULT DAYCARE, LLC
Other - Org Name:YOUNG IN SPIRIT ADULT DAY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BONE
Authorized Official - Suffix:
Authorized Official - Credentials:R,N,
Authorized Official - Phone:314-802-8384
Mailing Address - Street 1:2639 MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-3929
Mailing Address - Country:US
Mailing Address - Phone:314-802-8384
Mailing Address - Fax:314-802-8385
Practice Address - Street 1:2639 MIAMI ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3929
Practice Address - Country:US
Practice Address - Phone:314-802-8384
Practice Address - Fax:314-802-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO916261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO296246002Medicaid