| Organization Name: | SUPRA SENIORS LLC |
| NPI Number: | 1326241803 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DAVIS LANE ALLEN (EXECUTIVE DIRECTOR) |
| Mailing Address: | 524 S Elm Ave Webster Groves |
| State: | MO US |
| Postal Code: | 63119 |
| Phone Number: | 3149682222 |
| Fax Number: | 3149682224 |
| NPI Enumeration Date: | 06/11/2007 |
| NPI Last Update Date: | 07/25/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QA0600X |
| License Number: | 685 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MO |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Adult Day Care |
| Taxonomy Definition: | |