Healthcare Provider Details

I. General information

NPI: 1295839702
Provider Name (Legal Business Name): KIRKWOOD DIAGNOSTIC & ORTHOPEDIC ASSOCIATES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S KIRKWOOD RD SUITE 203
SAINT LOUIS MO
63122-6161
US

IV. Provider business mailing address

333 S KIRKWOOD RD SUITE 203
SAINT LOUIS MO
63122-6161
US

V. Phone/Fax

Practice location:
  • Phone: 314-909-1666
  • Fax: 314-909-7406
Mailing address:
  • Phone: 314-909-1666
  • Fax: 314-909-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number109216
License Number StateMO

VIII. Authorized Official

Name: DAVE HORACE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 314-909-1666