Healthcare Provider Details

I. General information

NPI: 1962070235
Provider Name (Legal Business Name): PAIGE BENTEN DIEPENBROCK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 RONNIES PLZ
SAINT LOUIS MO
63126-3552
US

IV. Provider business mailing address

17 RONNIES PLZ
SAINT LOUIS MO
63126-3552
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-2020
  • Fax:
Mailing address:
  • Phone: 314-843-2020
  • Fax: 314-843-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2021020950
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: