Provider Demographics
NPI:1174298483
Name:GWD ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:GWD ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERNISIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-246-9852
Mailing Address - Street 1:11423 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2724
Mailing Address - Country:US
Mailing Address - Phone:314-246-9852
Mailing Address - Fax:
Practice Address - Street 1:11423 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63044-2724
Practice Address - Country:US
Practice Address - Phone:314-246-9852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities