Healthcare Provider Details

I. General information

NPI: 1093235129
Provider Name (Legal Business Name): JMJ MEDICAL ENTERPRISE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8790 WATSON RD STE 201
SAINT LOUIS MO
63119-5140
US

IV. Provider business mailing address

8790 WATSON RD STE 201
SAINT LOUIS MO
63119-5140
US

V. Phone/Fax

Practice location:
  • Phone: 314-774-0300
  • Fax: 844-600-1085
Mailing address:
  • Phone: 314-774-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberR5P40
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR5P40
License Number StateMO

VIII. Authorized Official

Name: MR. NOEL CASINO
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 314-283-8950