Provider Demographics
NPI:1073349577
Name:MILITIA OF GRACE ADULT CARE CENTER 'LLC'
Entity type:Organization
Organization Name:MILITIA OF GRACE ADULT CARE CENTER 'LLC'
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BJ
Authorized Official - Middle Name:T
Authorized Official - Last Name:BUCHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-828-0804
Mailing Address - Street 1:4266 E NATURAL BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-3311
Mailing Address - Country:US
Mailing Address - Phone:314-828-0804
Mailing Address - Fax:
Practice Address - Street 1:4266 E NATURAL BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-3311
Practice Address - Country:US
Practice Address - Phone:314-828-0804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-11
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care