Provider Demographics
NPI:1598323115
Name:PROCARE ISL, LLC
Entity Type:Organization
Organization Name:PROCARE ISL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIGRE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-757-0188
Mailing Address - Street 1:2040 WOODSON RD STE 203B
Mailing Address - Street 2:
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2040 WOODSON RD STE 203B
Practice Address - Street 2:
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-5606
Practice Address - Country:US
Practice Address - Phone:314-755-1444
Practice Address - Fax:314-755-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities