Provider Demographics
NPI:1689231169
Name:HALL, PATRICE EDORA
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:EDORA
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 GREENWAY MANOR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033
Mailing Address - Country:US
Mailing Address - Phone:314-838-2393
Mailing Address - Fax:314-838-2616
Practice Address - Street 1:500 GREENWAY MANOR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033
Practice Address - Country:US
Practice Address - Phone:314-838-2393
Practice Address - Fax:314-838-2616
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO374U00000XMedicaid