Healthcare Provider Details

I. General information

NPI: 1346630803
Provider Name (Legal Business Name): AGM IOP/PHP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10199 WOODFIELD LN
OLIVETTE MO
63132-2922
US

IV. Provider business mailing address

10199 WOODFIELD LN
OLIVETTE MO
63132-2922
US

V. Phone/Fax

Practice location:
  • Phone: 314-282-2517
  • Fax: 314-845-2798
Mailing address:
  • Phone: 314-222-0602
  • Fax: 314-675-6681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLC001426559
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberLC001426559
License Number StateMO

VIII. Authorized Official

Name: DR. FRANCO SICURO
Title or Position: OWNER
Credential: M.D.
Phone: 314-222-0602