Provider Demographics
NPI:1457924755
Name:LACLEDE GROVES
Entity Type:Organization
Organization Name:LACLEDE GROVES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTH SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:OTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:314-446-2462
Mailing Address - Street 1:727 S LACLEDE STATION RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-4911
Mailing Address - Country:US
Mailing Address - Phone:314-446-2462
Mailing Address - Fax:314-446-2397
Practice Address - Street 1:727 S LACLEDE STATION RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-4911
Practice Address - Country:US
Practice Address - Phone:314-446-2462
Practice Address - Fax:314-446-2397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty