Healthcare Provider Details

I. General information

NPI: 1518872845
Provider Name (Legal Business Name): ELITE DIAGNOSTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 OLIVE ST
SAINT LOUIS MO
63101-1908
US

IV. Provider business mailing address

1105 OLIVE ST
SAINT LOUIS MO
63101-1908
US

V. Phone/Fax

Practice location:
  • Phone: 314-347-6007
  • Fax: 314-347-6007
Mailing address:
  • Phone: 314-347-6007
  • Fax: 314-347-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: KETURAH WILSON
Title or Position: MEMBER
Credential:
Phone: 314-347-6007