Healthcare Provider Details

I. General information

NPI: 1679828222
Provider Name (Legal Business Name): WELLHEALTH GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 OLIVE ST SUITE 0304
SAINT LOUIS MO
63101-1459
US

IV. Provider business mailing address

6614 CLAYTON RD SUITE 133
SAINT LOUIS MO
63117-1602
US

V. Phone/Fax

Practice location:
  • Phone: 314-925-7525
  • Fax: 314-925-7525
Mailing address:
  • Phone: 314-925-7525
  • Fax: 314-925-7525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1999137880
License Number StateMO

VIII. Authorized Official

Name: DR. LOON-TZIAN LO
Title or Position: DIRECTOR
Credential: MD
Phone: 314-925-7525