Healthcare Provider Details

I. General information

NPI: 1699824987
Provider Name (Legal Business Name): HEALTHMARK GRAVOIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 LANDMARK PARKWAY DR STE 102
SAINT LOUIS MO
63127-1665
US

IV. Provider business mailing address

11600 MANCHESTER RD STE 1O1
SAINT LOUIS MO
63131-4691
US

V. Phone/Fax

Practice location:
  • Phone: 314-446-0050
  • Fax: 314-822-8476
Mailing address:
  • Phone: 314-446-0050
  • Fax: 314-822-8476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARY SUE EKSTROM
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-446-0050