Healthcare Provider Details

I. General information

NPI: 1093339590
Provider Name (Legal Business Name): DAVID HENRY ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6643 SHEPLEY DR
SAINT LOUIS MO
63105-2354
US

IV. Provider business mailing address

6209 THOLOZAN AVE
SAINT LOUIS MO
63109-1367
US

V. Phone/Fax

Practice location:
  • Phone: 314-935-6677
  • Fax:
Mailing address:
  • Phone: 314-435-9713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2015038420
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: