Healthcare Provider Details

I. General information

NPI: 1780488551
Provider Name (Legal Business Name): ALIVIA JACHIMIAK STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

1061 N SHERMAN DR UNIT B
ROYAL OAK MI
48067-2276
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-9870
  • Fax:
Mailing address:
  • Phone: 574-344-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: