Healthcare Provider Details

I. General information

NPI: 1699750695
Provider Name (Legal Business Name): CARDIAC DIAGNOSTIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 08/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD SUITE 281B
SAINT LOUIS MO
63128-2141
US

IV. Provider business mailing address

10004 KENNERLY RD SUITE 281B
SAINT LOUIS MO
63128-2141
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5270
  • Fax: 314-543-5289
Mailing address:
  • Phone: 314-543-5270
  • Fax: 314-543-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number4560
License Number StateMO

VIII. Authorized Official

Name: MS. CAT LOPEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-543-5270