Healthcare Provider Details

I. General information

NPI: 1740245901
Provider Name (Legal Business Name): ST. LOUIS SURGICAL CENTER, LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 OFFICE PKWY
CREVE COEUR MO
63141-7105
US

IV. Provider business mailing address

760 OFFICE PKWY
CREVE COEUR MO
63141-7105
US

V. Phone/Fax

Practice location:
  • Phone: 314-995-4700
  • Fax: 314-995-4701
Mailing address:
  • Phone: 314-995-4700
  • Fax: 314-995-4701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number151-1
License Number StateMO

VIII. Authorized Official

Name: JENETHA D MORAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3893