1609242619 NPI number — THE HEALTH & WELLNESS CENTER FOR MEN, 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 1609242619 NPI number — THE HEALTH & WELLNESS CENTER FOR MEN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE HEALTH & WELLNESS CENTER FOR MEN, 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:
1609242619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9717 LANDMARK PARKWAY DR
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63127-1628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-722-6555
Provider Business Mailing Address Fax Number:
314-722-6551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9717 LANDMARK PARKWAY DR
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63127-1628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-722-6555
Provider Business Practice Location Address Fax Number:
314-722-6551
Provider Enumeration Date:
08/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SCHODROSKI
Authorized Official First Name:
SECIL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-722-6555

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  2014014296 , 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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