Healthcare Provider Details

I. General information

NPI: 1952140535
Provider Name (Legal Business Name): RESTORE CENTER FOR ENDOMETRIOSIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12812 TESSON FERRY RD
SAINT LOUIS MO
63128-2913
US

IV. Provider business mailing address

12812 TESSON FERRY RD
SAINT LOUIS MO
63128-2913
US

V. Phone/Fax

Practice location:
  • Phone: 314-970-1040
  • Fax: 314-970-1042
Mailing address:
  • Phone: 314-970-1040
  • Fax: 314-970-1042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: ADRIENNE GRIFFARD
Title or Position: BUSINESS MANAGER
Credential:
Phone: 636-209-2360