Provider Demographics
NPI:1053021865
Name:CONCORDANCE ACADEMY OF LEADERSHIP
Entity type:Organization
Organization Name:CONCORDANCE ACADEMY OF LEADERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:314-396-6004
Mailing Address - Street 1:6 CITYPLACE DR STE 522
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7209
Mailing Address - Country:US
Mailing Address - Phone:314-396-6004
Mailing Address - Fax:
Practice Address - Street 1:1845 BORMAN CT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4126
Practice Address - Country:US
Practice Address - Phone:314-396-6001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)