Healthcare Provider Details

I. General information

NPI: 1962785295
Provider Name (Legal Business Name): SPINNAKERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15620 MANCHESTER RD SUITE 33
ELLISVILLE MO
63011-2276
US

IV. Provider business mailing address

16029 MEADOW OAK DR
CHESTERFIELD MO
63017-7242
US

V. Phone/Fax

Practice location:
  • Phone: 314-757-7244
  • Fax: 757-215-0779
Mailing address:
  • Phone: 314-757-7244
  • Fax: 757-215-0779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number26D2031980
License Number StateMO

VIII. Authorized Official

Name: MR. ZIA IQBAL
Title or Position: CEO
Credential:
Phone: 314-757-7244