Healthcare Provider Details

I. General information

NPI: 1215688940
Provider Name (Legal Business Name): WILLIAM PARKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12166 OLD BIG BEND RD
KIRKWOOD MO
63122-6844
US

IV. Provider business mailing address

12166 OLD BIG BEND RD
KIRKWOOD MO
63122-6844
US

V. Phone/Fax

Practice location:
  • Phone: 314-822-8888
  • Fax:
Mailing address:
  • Phone: 314-822-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2021049879
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: