Healthcare Provider Details

I. General information

NPI: 1770596884
Provider Name (Legal Business Name): WARRENTON FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 E BOONESLICK RD SUITE ONE
WARRENTON MO
63383-2127
US

IV. Provider business mailing address

605 E BOONESLICK RD SUITE ONE
WARRENTON MO
63383-2127
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-1448
  • Fax: 636-456-9093
Mailing address:
  • Phone: 636-456-1448
  • Fax: 636-456-9093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number2005019582
License Number StateMO

VIII. Authorized Official

Name: DR. CHRISTOPHER GENE GRAVES
Title or Position: PHYSICIAN/OWNER
Credential: DO
Phone: 636-456-1448