1053691709 NPI number — S&J OF SOUTH COUNTY LLC

Table of content: (NPI 1053691709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053691709 NPI number — S&J OF SOUTH COUNTY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S&J OF SOUTH COUNTY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ALLERGY CARE SPECIALISTS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053691709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 LONG MEADOWS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63131-3014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-302-0736
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11188 TESSON FERRY RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63123-6962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-717-6717
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOO
Authorized Official First Name:
SHIRLEY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
314-302-0736

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  2001009169 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1144262825 . This is a "NPI" identifier . This identifiers is of the category "OTHER".