Healthcare Provider Details

I. General information

NPI: 1083612253
Provider Name (Legal Business Name): MBS ADVANTAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 03/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11618 GRAVOIS RD
SAINT LOUIS MO
63126-3014
US

IV. Provider business mailing address

11618 GRAVOIS RD
SAINT LOUIS MO
63126-3014
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-1900
  • Fax: 314-842-9185
Mailing address:
  • Phone: 314-842-1900
  • Fax: 314-842-9185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number207927
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number102623
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146004057
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number000014833
License Number StateMO

VIII. Authorized Official

Name: MS. JEAN L FOSTER
Title or Position: PRESIDENT
Credential: MA/CCC-SLP, BRS-S
Phone: 314-842-1900