MEDICARE: JOEL GIBBONS VICKERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	2019042607	MO

General Provider Information

NPI Number	:	1306502398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL GIBBONS VICKERY

Provider Business Mailing Address
First Line	:	208 N 9TH ST APT 312
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63101-1437
Country	:	US
Telephone Number	:	314-713-9144
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 N 9TH ST APT 312
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63101-1437
Country	:	US
Telephone Number	:	314-713-9144
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2021
Last Update Date	:	11/13/2021

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