MEDICARE: INSTACLINIC, LLC

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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000045196	OTHER	MO	NEW PTAN MASS IMMUNIZER PROVIDER NUMBER

General Provider Information

NPI Number	:	1497771653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTACLINIC, LLC

Provider Business Mailing Address
First Line	:	10805 SUNSET OFFICE DR
Second Line	:	SUITE 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63127-1017
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10805 SUNSET OFFICE DR
Second Line	:	SUITE 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63127-1017
Country	:	US
Telephone Number	:	314-892-7575
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, CEO
Name	:	MS. PATRICIA SOHN
Credential	:	RN
Telephone Number	:	314-406-5312

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	05/29/2008

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