Healthcare Provider Details

I. General information

NPI: 1790306421
Provider Name (Legal Business Name): INTENTIONAL LIVING PRIMARY HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S 6TH ST STE 110
SAINT LOUIS MO
63104-3602
US

IV. Provider business mailing address

1120 S 6TH ST STE 110
SAINT LOUIS MO
63104-3602
US

V. Phone/Fax

Practice location:
  • Phone: 314-203-2627
  • Fax: 314-261-9469
Mailing address:
  • Phone: 314-203-2627
  • Fax: 314-261-9469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARINA FISCHER
Title or Position: FAMILY NURSE PRACTITONER
Credential:
Phone: 618-977-1305