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General NPI Number Information
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NPI Number | 1053691709
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Entity Type | Organization
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Legal Business Name | S&J OF SOUTH COUNTY LLC
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Dates
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Enumeration Date | 08/26/2011
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Last Update Date | 12/15/2014
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Provider Practice Location Address
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Address Line | 11188 TESSON FERRY RD SUITE 101
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City | SAINT LOUIS
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State | MO
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Zip | 63123-6962
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Country | US
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Telephone | 636-717-6717
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Fax |
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Provider Business Mailing Address
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Address Line | 10 LONG MEADOWS LN
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City | SAINT LOUIS
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State | MO
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Zip | 63131-3014
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Country | US
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Telephone | 314-302-0736
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. SHIRLEY S JOO
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Credential | M.D.
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Telephone | 314-302-0736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | 2001009169
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License Number State | MO
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