Provider Demographics
NPI:1801114798
Name:CENTER STAGE, INC
Entity type:Organization
Organization Name:CENTER STAGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALFREDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:314-533-6600
Mailing Address - Street 1:3923 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3507
Mailing Address - Country:US
Mailing Address - Phone:314-533-6600
Mailing Address - Fax:314-533-6601
Practice Address - Street 1:3923 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3507
Practice Address - Country:US
Practice Address - Phone:314-533-6600
Practice Address - Fax:314-533-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC9274711253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM285894309Medicaid
MOM265894303Medicaid