1649453796 NPI number — SOUTHSIDE WELLNESS CENTER INC

Table of content: (NPI 1649453796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649453796 NPI number — SOUTHSIDE WELLNESS CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE WELLNESS CENTER INC
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:
Provider Other Organization Name Type Code:
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:
1649453796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3017 PARK AVE
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:
63104-1433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-664-5024
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3017 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63104-1433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-664-5024
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARRAM
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
314-664-5024

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0600X , with the licence number: 291705606 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X , with the licence number: 851705608 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 372500000X , with the licence number: 281705608 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747P1801X , with the licence number: 261705602 , 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: 0000466 . This is a "PROVIDER NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 291705606 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 261705602 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281705608 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 851705608 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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