Healthcare Provider Details

I. General information

NPI: 1003392697
Provider Name (Legal Business Name): AFFINIA HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 WASHINGTON AVE
SAINT LOUIS MO
63103-1306
US

IV. Provider business mailing address

PO BOX 551
SAINT LOUIS MO
63188-0551
US

V. Phone/Fax

Practice location:
  • Phone: 314-898-1700
  • Fax: 314-814-8542
Mailing address:
  • Phone: 314-898-1700
  • Fax: 314-814-8542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CORINTHIA DARCEL JAMISON
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 314-814-8531