MEDICARE: DCCT

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	101819	MO

General Provider Information

NPI Number	:	1588818975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DCCT

Provider Business Mailing Address
First Line	:	PO BOX 9169
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-0169
Country	:	US
Telephone Number	:	314-610-8169
Fax Number	:

Provider Business Practice Location Address
First Line	:	1423 S BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2203
Country	:	US
Telephone Number	:	314-610-8169
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. REZA ROFOUGARAN
Credential	:	MD
Telephone Number	:	314-610-8169

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	11/13/2008

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