Healthcare Provider Details

I. General information

NPI: 1144778648
Provider Name (Legal Business Name): KIDNEXXIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4271 CASTLEMAN AVE
SAINT LOUIS MO
63110-3502
US

IV. Provider business mailing address

4271 CASTLEMAN AVE
SAINT LOUIS MO
63110-3502
US

V. Phone/Fax

Practice location:
  • Phone: 618-219-6501
  • Fax:
Mailing address:
  • Phone: 618-219-6501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number005449
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number005449
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number005449
License Number StateMO

VIII. Authorized Official

Name: EMILY KORTE-STROFF
Title or Position: PRESIDENT/OWNER
Credential: OTR/L
Phone: 618-219-6501