Healthcare Provider Details

I. General information

NPI: 1346820123
Provider Name (Legal Business Name): REZILIENT OLH PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7923 FORSYTH BLVD
CLAYTON MO
63105-3808
US

IV. Provider business mailing address

5595 PERSHING AVE
SAINT LOUIS MO
63112-1703
US

V. Phone/Fax

Practice location:
  • Phone: 314-912-4234
  • Fax: 314-887-5157
Mailing address:
  • Phone: 314-912-4234
  • Fax: 314-887-5159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CALLISTA FINK
Title or Position: CARE OPERATIONS COORDINATOR
Credential:
Phone: 314-328-8331