1376802678 NPI number — COMPREHENSIVE INDEPENDENT GOALS INC ST. LOUIS CONSUMER DIRECTED SERVIC

Table of content: REBECCA ADAMS ARNP (NPI 1063882264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376802678 NPI number — COMPREHENSIVE INDEPENDENT GOALS INC ST. LOUIS CONSUMER DIRECTED SERVIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE INDEPENDENT GOALS INC ST. LOUIS CONSUMER DIRECTED SERVIC
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:
1376802678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 66037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70896-6037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-926-5190
Provider Business Mailing Address Fax Number:
225-926-6964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 N KINGSHIGHWAY BLVD
Provider Second Line Business Practice Location Address:
SUITE - 6
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63108-1378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-361-7337
Provider Business Practice Location Address Fax Number:
314-361-3361
Provider Enumeration Date:
05/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MCGOWAN
Authorized Official First Name:
RONNIE
Authorized Official Middle Name:
MAX
Authorized Official Title or Position:
PRES./C. F. O.
Authorized Official Telephone Number:
314-361-7337

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1157384 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1173835 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1642649 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1104137041 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1157392 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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