Healthcare Provider Details

I. General information

NPI: 1467106401
Provider Name (Legal Business Name): ALAINA ALTENBERND OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5694 TELEGRAPH RD
SAINT LOUIS MO
63129-4243
US

IV. Provider business mailing address

111 E 4TH ST STE 440
ALTON IL
62002-6241
US

V. Phone/Fax

Practice location:
  • Phone: 314-846-4222
  • Fax:
Mailing address:
  • Phone: 618-462-9818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2022023009
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: