Provider Demographics
NPI:1053796219
Name:MARDRAS MARVELOUS MISSION I LLC
Entity type:Organization
Organization Name:MARDRAS MARVELOUS MISSION I LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:BSN RN
Authorized Official - Phone:314-659-9090
Mailing Address - Street 1:3830 WASHINGTON BLVD
Mailing Address - Street 2:STE 109
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3460
Mailing Address - Country:US
Mailing Address - Phone:636-465-3004
Mailing Address - Fax:314-833-3170
Practice Address - Street 1:3830 WASHINGTON BLVD
Practice Address - Street 2:STE 109
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3460
Practice Address - Country:US
Practice Address - Phone:314-659-9090
Practice Address - Fax:314-833-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODHSSMedicaid