Healthcare Provider Details

I. General information

NPI: 1659580157
Provider Name (Legal Business Name): ONE SOURCE HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 EVERGREEN LN APT E
SAINT LOUIS MO
63125-4804
US

IV. Provider business mailing address

3430 EVERGREEN LN APT E
SAINT LOUIS MO
63125-4804
US

V. Phone/Fax

Practice location:
  • Phone: 314-304-3591
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1
License Number StateMO

VIII. Authorized Official

Name: MAURICE AYIDIYA
Title or Position: OWNER
Credential:
Phone: 314-304-3591