Organization
SOUTHSIDE WELLNESS CENTER INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARY PARRAM (ASSISTANT DIRECTOR)
(314) 664-5024
Entity
Organization
Contact information
Practice address
3017 PARK AVE, SAINT LOUIS, MO 63104-1433
(314) 664-5024
Mailing address
3017 PARK AVE, SAINT LOUIS, MO 63104-1433
(314) 664-5024
Taxonomy
Speciality
Code
Description
License number
State
251E00000X
Home Health Agency
—
MO
261QA0600X
Adult Day Care Clinic/Center
291705606
MO
343900000X
Non-emergency Medical Transport (VAN)
851705608
MO
372500000X
Chore Provider
281705608
MO
3747P1801X
Personal Care Attendant
Primary
261705602
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000466
PROVIDER NUMBER
MO
05
—
261705602
—
MO
05
—
281705608
—
MO
05
—
291705606
—
MO
05
—
851705608
—
MO
Enumeration date
12/12/2007
Last updated
05/16/2008
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