Healthcare Provider Details

I. General information

NPI: 1295467306
Provider Name (Legal Business Name): MALIK ST LOUIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5408 S BROADWAY
ST LOUIS MO
63111-2023
US

IV. Provider business mailing address

2215 BROADWAY ST
CAPE GIRARDEAU MO
63701-4403
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-7225
  • Fax:
Mailing address:
  • Phone: 573-335-3044
  • Fax: 573-335-6724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. SHAFIQ MALIK
Title or Position: PRESIDENT
Credential:
Phone: 573-335-3044