Provider Demographics
NPI:1346886488
Name:CELEBRATION CITY COMMUNITY CENTER
Entity Type:Organization
Organization Name:CELEBRATION CITY COMMUNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRIENTISS
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:BS THEOLOGY, D DIVI
Authorized Official - Phone:314-761-6132
Mailing Address - Street 1:1703 STONEY TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7783
Mailing Address - Country:US
Mailing Address - Phone:314-761-6132
Mailing Address - Fax:314-449-1338
Practice Address - Street 1:4130 E LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-3333
Practice Address - Country:US
Practice Address - Phone:314-261-4348
Practice Address - Fax:313-449-1338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAME AS ABOVE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO29Medicaid