Healthcare Provider Details

I. General information

NPI: 1639914609
Provider Name (Legal Business Name): MONTACER BELFANCHA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLZ
LAKE ST LOUIS MO
63367-1366
US

IV. Provider business mailing address

100 MEDICAL PLZ
LAKE ST LOUIS MO
63367-1366
US

V. Phone/Fax

Practice location:
  • Phone: 636-584-4803
  • Fax:
Mailing address:
  • Phone: 636-584-4803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2024030419
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2014004753
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: