Healthcare Provider Details

I. General information

NPI: 1053691709
Provider Name (Legal Business Name): S&J OF SOUTH COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 12/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11188 TESSON FERRY RD SUITE 101
SAINT LOUIS MO
63123-6962
US

IV. Provider business mailing address

10 LONG MEADOWS LN
SAINT LOUIS MO
63131-3014
US

V. Phone/Fax

Practice location:
  • Phone: 636-717-6717
  • Fax:
Mailing address:
  • Phone: 314-302-0736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number2001009169
License Number StateMO

VIII. Authorized Official

Name: DR. SHIRLEY S JOO
Title or Position: MANAGER
Credential: M.D.
Phone: 314-302-0736