Healthcare Provider Details

I. General information

NPI: 1285521294
Provider Name (Legal Business Name): OLDE TYME HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4949 DIAMOND DR
HIGH RIDGE MO
63049-2760
US

IV. Provider business mailing address

4949 DIAMOND DR
HIGH RIDGE MO
63049-2760
US

V. Phone/Fax

Practice location:
  • Phone: 314-562-6411
  • Fax:
Mailing address:
  • Phone: 314-562-6411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHERI E DUNAWAY
Title or Position: OWNER
Credential:
Phone: 314-562-6411