Healthcare Provider Details

I. General information

NPI: 1447669767
Provider Name (Legal Business Name): PERSONAL CARE MEDICAL ENTERPRISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5933 S HIGHWAY 94 SUITE 102
WELDON SPRING MO
63304-5610
US

IV. Provider business mailing address

5933 S HIGHWAY 94 SUITE 102
WELDON SPRING MO
63304-5610
US

V. Phone/Fax

Practice location:
  • Phone: 636-477-6085
  • Fax:
Mailing address:
  • Phone: 636-477-6085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberLC1363451
License Number StateMO

VIII. Authorized Official

Name: MR. NICOLAS WIEGAND
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 636-477-6085