Healthcare Provider Details

I. General information

NPI: 1508308578
Provider Name (Legal Business Name): ISAIAH'S ANGELS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5261 DELMAR BLVD SUITE 210B
SAINT LOUIS MO
63108-1063
US

IV. Provider business mailing address

8739 AGATE CT
SAINT LOUIS MO
63136-3700
US

V. Phone/Fax

Practice location:
  • Phone: 314-322-3994
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberLC9814999
License Number StateMO

VIII. Authorized Official

Name: MS. CAROLYN WARREN
Title or Position: DIRECTOR
Credential:
Phone: 314-322-3994