1053449579 NPI number — LIFEVISION, INC.

Table of content: (NPI 1053449579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053449579 NPI number — LIFEVISION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFEVISION, 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:
6
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:
1053449579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
338 S KIRKWOOD RD
Provider Second Line Business Mailing Address:
UNIT 104B
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63122-6166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-984-0068
Provider Business Mailing Address Fax Number:
314-984-0338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
338 S KIRKWOOD RD
Provider Second Line Business Practice Location Address:
UNIT 104B
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63122-6166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-984-0068
Provider Business Practice Location Address Fax Number:
314-984-0338
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OPENLANDER
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
314-984-0068

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  00923 , 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: 115373 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 5769225 . This is a "AETNA PROVIDER ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 64-01386 . This is a "UNITED HEALTHCARE PROVIDE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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