Healthcare Provider Details

I. General information

NPI: 1902816077
Provider Name (Legal Business Name): AFFINIA HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 BIDDLE ST
SAINT LOUIS MO
63106-3454
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:
Mailing address:
  • Phone: 314-814-8515
  • Fax: 314-814-8542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number507226801
License Number StateMO

VIII. Authorized Official

Name: MRS. JANET VOSS
Title or Position: CFO
Credential:
Phone: 314-814-8571