Healthcare Provider Details

I. General information

NPI: 1710504576
Provider Name (Legal Business Name): ANITA LYNN HOLBROOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2020
Last Update Date: 06/28/2020
Certification Date: 06/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4603 NATURAL BRIDGE AVE
SAINT LOUIS MO
63115-1922
US

IV. Provider business mailing address

4603 NATURAL BRIDGE AVE
SAINT LOUIS MO
63115-1922
US

V. Phone/Fax

Practice location:
  • Phone: 314-833-4603
  • Fax:
Mailing address:
  • Phone: 314-833-4603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number088456
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: