Healthcare Provider Details

I. General information

NPI: 1457628935
Provider Name (Legal Business Name): MR. EDWARD TIMOTHY ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 SAVANNAH RIDGE DR
SAINT CHARLES MO
63303-2918
US

IV. Provider business mailing address

405 SAVANNAH RIDGE DR
SAINT CHARLES MO
63303-2918
US

V. Phone/Fax

Practice location:
  • Phone: 636-244-0704
  • Fax: 636-244-0704
Mailing address:
  • Phone: 636-244-0704
  • Fax: 636-244-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number084580
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: