Healthcare Provider Details

I. General information

NPI: 1881392074
Provider Name (Legal Business Name): GRETA TAMKUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

885 TIVERTON AVE
LOS ANGELES CA
90095-0001
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-5060
  • Fax:
Mailing address:
  • Phone: 310-825-6373
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: