Healthcare Provider Details

I. General information

NPI: 1992305007
Provider Name (Legal Business Name): PROFICIENT WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 WOODSON RD
OVERLAND MO
63114-5644
US

IV. Provider business mailing address

2050 WOODSON RD
OVERLAND MO
63114-5644
US

V. Phone/Fax

Practice location:
  • Phone: 314-447-0725
  • Fax:
Mailing address:
  • Phone: 314-447-0725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: EDGAR EVERETT
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 314-447-0725