Provider Demographics
NPI:1750682043
Name:BLACK ALCOHOL/DRUG SERVICE INFORMATION CENTER
Entity Type:Organization
Organization Name:BLACK ALCOHOL/DRUG SERVICE INFORMATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NINA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-621-9009
Mailing Address - Street 1:3026 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1329
Mailing Address - Country:US
Mailing Address - Phone:314-621-9009
Mailing Address - Fax:314-621-1071
Practice Address - Street 1:3026 LOCUST ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1329
Practice Address - Country:US
Practice Address - Phone:314-621-9009
Practice Address - Fax:314-621-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8043261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1346372380OtherEXISTING NPI
MO866202708Medicaid