Healthcare Provider Details

I. General information

NPI: 1295134633
Provider Name (Legal Business Name): ST LOUIS REGENERATIVE MEDICINE AND PAIN INSTITUTE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4116 VON TALGE RD SUITE B
SAINT LOUIS MO
63128-1957
US

IV. Provider business mailing address

4116 VON TALGE ROAD SUITE B
ST LOUIS MO
63128
US

V. Phone/Fax

Practice location:
  • Phone: 314-892-8787
  • Fax: 314-892-8790
Mailing address:
  • Phone: 314-892-8787
  • Fax: 314-892-8790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. WILLIAM TALBOTT SCHMIDT
Title or Position: MANAGER
Credential:
Phone: 314-892-8787