Healthcare Provider Details

I. General information

NPI: 1275949927
Provider Name (Legal Business Name): COMPREHENSIVE CARE OF NEPHROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 OLD BALLAS RD STE 104
SAINT LOUIS MO
63141-7083
US

IV. Provider business mailing address

PO BOX 411392
SAINT LOUIS MO
63141-1392
US

V. Phone/Fax

Practice location:
  • Phone: 636-333-4500
  • Fax: 314-942-8695
Mailing address:
  • Phone: 636-333-4500
  • Fax: 314-942-8695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number109507
License Number StateMO

VIII. Authorized Official

Name: QING CHEN
Title or Position: OWNER
Credential: MD
Phone: 314-620-1848