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General NPI Number Information
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NPI Number | 1144094087
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Entity Type | Organization
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Legal Business Name | ST GABRIEL CLINIC CDM
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Dates
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Enumeration Date | 11/10/2023
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Last Update Date | 11/10/2023
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Provider Practice Location Address
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Address Line | 6115 RIDGE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63133-2616
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Country | US
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Telephone | 314-230-9050
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Fax | 844-870-7109
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Provider Business Mailing Address
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Address Line | 6115 RIDGE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63133-2616
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Country | US
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Telephone | 314-230-9050
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Fax | 844-870-7109
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Authorized Official
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Title or Position | OWNER
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Name | DR. DANIEL DESTA BEKELE
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Credential | MD
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Telephone | 720-235-6443
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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