1760662514 NPI number — SKIN SURGERY CENTER OF MISSOURI, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760662514 NPI number — SKIN SURGERY CENTER OF MISSOURI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKIN SURGERY CENTER OF MISSOURI, 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:
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:
1760662514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6704 KEATON CORPORATE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O FALLON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63368-8680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-300-9596
Provider Business Mailing Address Fax Number:
636-300-9598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6704 KEATON CORPORATE PKWY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63368-8680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-300-9596
Provider Business Practice Location Address Fax Number:
636-300-9598
Provider Enumeration Date:
11/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAZA
Authorized Official First Name:
SAADIA
Authorized Official Middle Name:
TAUFIQ
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
314-276-0385

Provider Taxonomy Codes

  • Taxonomy code: 207NS0135X , 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)





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