Healthcare Provider Details

I. General information

NPI: 1760778484
Provider Name (Legal Business Name): SOUTH COUNTY PAIN INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4116 VON TALGE RD
SAINT LOUIS MO
63128-1957
US

IV. Provider business mailing address

4116 VON TALGE RD
SAINT LOUIS MO
63128-1957
US

V. Phone/Fax

Practice location:
  • Phone: 314-324-0583
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: THOMAS KRAMER
Title or Position: PRESIDENT
Credential:
Phone: 314-324-0583