Healthcare Provider Details

I. General information

NPI: 1154793248
Provider Name (Legal Business Name): ELITE SURGICAL ASSISTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 DOUGHERTY FERRY RD STE 430
SAINT LOUIS MO
63122-3325
US

IV. Provider business mailing address

PO BOX 323
NEW MELLE MO
63365-0323
US

V. Phone/Fax

Practice location:
  • Phone: 888-826-4546
  • Fax: 888-826-4546
Mailing address:
  • Phone: 888-826-4546
  • Fax: 888-826-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. DARIN M. MINKIN
Title or Position: ADMINISTRATOR
Credential: D.O.
Phone: 314-965-8622