Healthcare Provider Details

I. General information

NPI: 1215119508
Provider Name (Legal Business Name): ALLERGY ASTHMA & IMMUNOLOGY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 ELM COURT
JEFFERSON CITY MO
65101-4129
US

IV. Provider business mailing address

1735 ELM COURT
JEFFERSON CITY MO
65101-4129
US

V. Phone/Fax

Practice location:
  • Phone: 573-638-2012
  • Fax: 573-761-4249
Mailing address:
  • Phone: 573-638-2012
  • Fax: 573-761-4249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number36946
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number0340248-22
License Number StateMO

VIII. Authorized Official

Name: DR. STANLEY RAYMOND HORNER
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 573-638-2012