Healthcare Provider Details

I. General information

NPI: 1356084206
Provider Name (Legal Business Name): CLIFFE OBANNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14600 MONDOUBLEAU LN
FLORISSANT MO
63034-2314
US

IV. Provider business mailing address

14600 MONDOUBLEAU LN
FLORISSANT MO
63034-2314
US

V. Phone/Fax

Practice location:
  • Phone: 202-378-4864
  • Fax:
Mailing address:
  • Phone: 202-378-4864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: