Healthcare Provider Details

I. General information

NPI: 1457862708
Provider Name (Legal Business Name): BETTY JEAN KERR PEOPLES HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 N FLORISSANT RD STE 101
FERGUSON MO
63135-2312
US

IV. Provider business mailing address

5701 DELMAR BLVD
SAINT LOUIS MO
63112-2617
US

V. Phone/Fax

Practice location:
  • Phone: 314-633-8921
  • Fax: 314-524-9227
Mailing address:
  • Phone: 314-367-7848
  • Fax: 314-367-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberN00015533
License Number StateMO

VIII. Authorized Official

Name: DWAYNE BUTLER
Title or Position: PRESIDENT & CEO
Credential:
Phone: 314-367-7848