Provider Demographics
NPI:1437389665
Name:MOMENTS OF SERENITY
Entity Type:Organization
Organization Name:MOMENTS OF SERENITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GILDEHAUS-BALLEYDIER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:636-390-0047
Mailing Address - Street 1:1380 HIGH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4396
Mailing Address - Country:US
Mailing Address - Phone:636-390-0047
Mailing Address - Fax:636-390-9424
Practice Address - Street 1:1380 HIGH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4396
Practice Address - Country:US
Practice Address - Phone:636-390-0047
Practice Address - Fax:636-390-9424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization