Healthcare Provider Details

I. General information

NPI: 1396175188
Provider Name (Legal Business Name): TRADEWINDS PALLIATIVE CARE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 KINGSBURY BLVD
FREDERICKTOWN MO
63645-7959
US

IV. Provider business mailing address

101 KINGSBURY BLVD
FREDERICKTOWN MO
63645-7959
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-7625
  • Fax: 573-783-2126
Mailing address:
  • Phone: 573-783-7625
  • Fax: 573-783-2126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP M BEYER
Title or Position: CEO/PRESIDENT
Credential: D.O.
Phone: 573-783-7625