Provider Demographics
NPI:1841460623
Name:ST LOUIS ARC
Entity type:Organization
Organization Name:ST LOUIS ARC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS, CFO
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TISONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-569-2211
Mailing Address - Street 1:1816 LACKLAND HILL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3507
Mailing Address - Country:US
Mailing Address - Phone:314-569-2211
Mailing Address - Fax:314-569-0778
Practice Address - Street 1:1228 DAUTEL
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146
Practice Address - Country:US
Practice Address - Phone:314-569-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO856274709Medicaid