1720169303 NPI number — FLORISSANT VALLEY FIRE PRO DIST

Table of content: (NPI 1720169303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720169303 NPI number — FLORISSANT VALLEY FIRE PRO DIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORISSANT VALLEY FIRE PRO DIST
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:
1720169303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 SAINT CATHERINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORISSANT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63031-4946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-538-8278
Provider Business Mailing Address Fax Number:
580-628-2273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 SAINT CATHERINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORISSANT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63031-4946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-538-8278
Provider Business Practice Location Address Fax Number:
580-628-2273
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLAUTER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
800-538-8278

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  189472 , 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: 805125903 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 129152 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 590014098 . This is a "RRMC PROVIDER NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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