Healthcare Provider Details

I. General information

NPI: 1063415073
Provider Name (Legal Business Name): KING'S MEDICAL IMAGING CREVE COEUR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11756 OLIVE STREET RD
CREVE COEUR MO
63141
US

IV. Provider business mailing address

1894 GEORGETOWN RD
HUDSON OH
44236-4058
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-3900
  • Fax: 314-569-2734
Mailing address:
  • Phone: 330-653-3968
  • Fax: 330-656-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MS. V. RENAE COYNE
Title or Position: DIRECTOR OF BILLING
Credential:
Phone: 330-653-3968