Healthcare Provider Details

I. General information

NPI: 1467789222
Provider Name (Legal Business Name): VA MEDICAL CENTER IN ST.LOUIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2009
Last Update Date: 11/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9830 EASTDELL DR
SAINT LOUIS MO
63136-1915
US

IV. Provider business mailing address

9830 EASTDELL DR
SAINT LOUIS MO
63136-1915
US

V. Phone/Fax

Practice location:
  • Phone: 314-484-0094
  • Fax:
Mailing address:
  • Phone: 314-484-0094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number2003003052
License Number StateMO

VIII. Authorized Official

Name: CHAMEL MARNIQUE TAYLOR
Title or Position: NURSING
Credential: RN
Phone: 314-484-0094