Healthcare Provider Details

I. General information

NPI: 1861033565
Provider Name (Legal Business Name): PRIMARY MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 EMERLING DR
SAINT LOUIS MO
63121-1022
US

IV. Provider business mailing address

206 EMERLING DR
SAINT LOUIS MO
63121-1022
US

V. Phone/Fax

Practice location:
  • Phone: 314-390-8850
  • Fax:
Mailing address:
  • Phone: 314-390-8850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name: MR. QUINTEN RANDOLPH
Title or Position: OWNER
Credential:
Phone: 314-390-8850