Healthcare Provider Details

I. General information

NPI: 1184106924
Provider Name (Legal Business Name): TAMARA T WOODSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6725 RAYMOND AVE
SAINT LOUIS MO
63133-1417
US

IV. Provider business mailing address

6725 RAYMOND AVE
SAINT LOUIS MO
63133-1417
US

V. Phone/Fax

Practice location:
  • Phone: 314-305-5406
  • Fax:
Mailing address:
  • Phone: 314-305-5406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: TAMARA T WOODSON
Title or Position: CNA
Credential: CNA
Phone: 314-305-5406