Healthcare Provider Details

I. General information

NPI: 1689742389
Provider Name (Legal Business Name): ST. LOUIS OFFICE FOR MRDD RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2334 OLIVE ST
SAINT LOUIS MO
63103-1531
US

IV. Provider business mailing address

2334 OLIVE ST
SAINT LOUIS MO
63103-1531
US

V. Phone/Fax

Practice location:
  • Phone: 314-421-0090
  • Fax: 314-421-2525
Mailing address:
  • Phone: 314-421-0090
  • Fax: 314-421-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: EMILY SMITH
Title or Position: FISCAL MANAGER
Credential:
Phone: 314-421-0090