Healthcare Provider Details

I. General information

NPI: 1770331761
Provider Name (Legal Business Name): SEVI LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 03/06/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SAINT PETERS CENTRE BLVD STE 250
SAINT PETERS MO
63376-1662
US

IV. Provider business mailing address

300 SAINT PETERS CENTRE BLVD STE 250
SAINT PETERS MO
63376-1662
US

V. Phone/Fax

Practice location:
  • Phone: 636-245-5126
  • Fax: 636-245-3235
Mailing address:
  • Phone: 636-245-5126
  • Fax: 636-245-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARIZELLE FLORES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 860-944-4766