Healthcare Provider Details

I. General information

NPI: 1568596922
Provider Name (Legal Business Name): WINGHAVEN PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5551 WINGHAVEN BLVD
O FALLON MO
63368-3617
US

IV. Provider business mailing address

5551 WINGHAVEN BLVD SUITE 240
O'FALLON MO
63368
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-5561
  • Fax: 636-561-5557
Mailing address:
  • Phone: 636-561-5561
  • Fax: 636-561-5557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: HOLLY LOEFFLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 636-561-5561