Healthcare Provider Details

I. General information

NPI: 1679013643
Provider Name (Legal Business Name): CITY DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 N KINGSHIGHWAY BLVD SUITE 224
SAINT LOUIS MO
63113-1400
US

IV. Provider business mailing address

1408 N KINGSHIGHWAY BLVD SUITE 224
SAINT LOUIS MO
63113-1400
US

V. Phone/Fax

Practice location:
  • Phone: 314-696-2489
  • Fax: 314-667-3212
Mailing address:
  • Phone: 314-696-2489
  • Fax: 314-667-3212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberLC001491707
License Number StateMO

VIII. Authorized Official

Name: SHANTAY K REED
Title or Position: OWNER
Credential:
Phone: 314-853-0469