Provider Demographics
NPI:1619533726
Name:ARDRENNA WHITE
Entity Type:Organization
Organization Name:ARDRENNA WHITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ARDRENNA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PROVIDER
Authorized Official - Phone:314-344-5005
Mailing Address - Street 1:3466 BRIDGELAND DR STE 2163466
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2626
Mailing Address - Country:US
Mailing Address - Phone:314-344-5002
Mailing Address - Fax:314-344-5003
Practice Address - Street 1:3466 BRIDGELAND DR STE 2163466
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2626
Practice Address - Country:US
Practice Address - Phone:314-344-5002
Practice Address - Fax:314-344-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO05Medicaid