Healthcare Provider Details

I. General information

NPI: 1356493811
Provider Name (Legal Business Name): FENTON FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 SMIZER STATION RD SUITE 5
FENTON MO
63026-2784
US

IV. Provider business mailing address

1747 SMIZER STATION RD SUITE 5
FENTON MO
63026-2784
US

V. Phone/Fax

Practice location:
  • Phone: 636-529-7000
  • Fax: 636-529-7003
Mailing address:
  • Phone: 636-529-7000
  • Fax: 636-529-7003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number115447
License Number StateMO

VIII. Authorized Official

Name: DR. BRENDA LYNN BUCKLEY
Title or Position: DOCTOR
Credential: M.D.
Phone: 636-529-7000