Healthcare Provider Details

I. General information

NPI: 1528297975
Provider Name (Legal Business Name): CORAM ALTERNATE SITE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13205 LAKEFRONT DR
EARTH CITY MO
63045-1503
US

IV. Provider business mailing address

PO BOX 809160
CHICAGO IL
60680-9160
US

V. Phone/Fax

Practice location:
  • Phone: 314-656-5110
  • Fax: 314-656-5005
Mailing address:
  • Phone: 303-672-8631
  • Fax: 303-298-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRICIA L LACAVICH
Title or Position: PRESIDENT
Credential:
Phone: 318-407-1785