MEDICARE: CITY DIAGNOSTICS 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	305R00000X	Preferred Provider Organization	LC001491707	MO

General Provider Information

NPI Number	:	1679013643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	1408 N KINGSHIGHWAY BLVD
Second Line	:	SUITE 224
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-1400
Country	:	US
Telephone Number	:	314-696-2489
Fax Number	:	314-667-3212

Provider Business Practice Location Address
First Line	:	1408 N KINGSHIGHWAY BLVD
Second Line	:	SUITE 224
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-1400
Country	:	US
Telephone Number	:	314-696-2489
Fax Number	:	314-667-3212

Authorized Official
Title or Position	:	OWNER
Name	:	SHANTAY K REED
Credential	:
Telephone Number	:	314-853-0469

Provider Enumeration Date	:	02/24/2017
Last Update Date	:	02/24/2017

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Directions to “CITY DIAGNOSTICS LLC ” Practice Location

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