Healthcare Provider Details

I. General information

NPI: 1376804898
Provider Name (Legal Business Name): FOREST PARK NEUROLOGY, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3431 S STATE ROUTE 291
INDEPENDENCE MO
64057-2341
US

IV. Provider business mailing address

3431 S STATE ROUTE 291
INDEPENDENCE MO
64057-2341
US

V. Phone/Fax

Practice location:
  • Phone: 816-600-1816
  • Fax: 816-795-6966
Mailing address:
  • Phone: 816-600-1816
  • Fax: 816-795-6966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2008002407
License Number StateMO

VIII. Authorized Official

Name: DR. MARIA LOURDES DONATO
Title or Position: OFFICE MANAGER
Credential: M.D.
Phone: 816-600-1816