Healthcare Provider Details

I. General information

NPI: 1851071898
Provider Name (Legal Business Name): FORTIETH & VINEYARD COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10781 NORTH OUTER 40 ROAD 117
CHESTERFIELD MO
63005
US

IV. Provider business mailing address

2369 WESFORD DR
MARYLAND HEIGHTS MO
63043-4147
US

V. Phone/Fax

Practice location:
  • Phone: 314-496-0178
  • Fax:
Mailing address:
  • Phone: 314-496-0178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: MRS. STACEY YVONNE PEGUES
Title or Position: CRANIAL PROSTHESIS SPECIALISTS
Credential: SPECIALIST
Phone: 314-496-0178