Provider Demographics
NPI:1861830093
Name:DEVINE CARE CONSUMER DIRECT SERVICES,LLC
Entity Type:Organization
Organization Name:DEVINE CARE CONSUMER DIRECT SERVICES,LLC
Other - Org Name:CLASSIC ADULTS DAY CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FOLASADE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYINMODU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-323-9426
Mailing Address - Street 1:3236 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-3733
Mailing Address - Country:US
Mailing Address - Phone:314-856-9393
Mailing Address - Fax:314-856-9677
Practice Address - Street 1:3236 PARKER RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-3733
Practice Address - Country:US
Practice Address - Phone:314-856-9393
Practice Address - Fax:314-856-9677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO842311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1801029673Medicaid