Healthcare Provider Details

I. General information

NPI: 1790343804
Provider Name (Legal Business Name): CALVIN AKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4432 W BELLE PL
SAINT LOUIS MO
63108-2617
US

IV. Provider business mailing address

4432 W BELLE PL
SAINT LOUIS MO
63108-2617
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-8908
  • Fax: 314-652-8819
Mailing address:
  • Phone: 314-652-8908
  • Fax: 314-652-8819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: