Provider Demographics
NPI:1336304450
Name:MAKE OVER FOR LIFE OUTREACH
Entity Type:Organization
Organization Name:MAKE OVER FOR LIFE OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:LANEEN
Authorized Official - Last Name:ESTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-226-9309
Mailing Address - Street 1:5218 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-1106
Mailing Address - Country:US
Mailing Address - Phone:314-226-9309
Mailing Address - Fax:
Practice Address - Street 1:5218 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-1106
Practice Address - Country:US
Practice Address - Phone:314-226-9309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========Medicaid