Healthcare Provider Details

I. General information

NPI: 1245135367
Provider Name (Legal Business Name): PROFESSIONAL HEALTH MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 ROTTINGDEAN DR APT E
SAINT LOUIS MO
63136-4668
US

IV. Provider business mailing address

2775 ROTTINGDEAN DR APT E
SAINT LOUIS MO
63136-4668
US

V. Phone/Fax

Practice location:
  • Phone: 314-449-9420
  • Fax:
Mailing address:
  • Phone: 314-449-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEJA SCOTT
Title or Position: OWNER
Credential:
Phone: 314-723-0127