Healthcare Provider Details

I. General information

NPI: 1205275138
Provider Name (Legal Business Name): BAVARIA MEDDAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 459 BOX 19908
APO AE
09139-0020
US

IV. Provider business mailing address

CMR 459 BOX 19908
APO AE
09139-0020
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-1750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number4704257576
License Number StateMI

VIII. Authorized Official

Name: DR. VINCENT BENTLEY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 314-469-1750