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General NPI Number Information
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NPI Number | 1275019408
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Entity Type | Organization
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Legal Business Name | MEN'S MEDICAL INSTITUTE LLC
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Dates
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Enumeration Date | 07/11/2018
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Last Update Date | 07/11/2018
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Provider Practice Location Address
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Address Line | 1062 OLD DES PERES RD
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City | SAINT LOUIS
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State | MO
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Zip | 63131-1865
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Country | US
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Telephone | 314-394-1660
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Fax | 314-394-1663
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Provider Business Mailing Address
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Address Line | 1062 OLD DES PERES RD
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City | SAINT LOUIS
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State | MO
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Zip | 63131-1865
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Country | US
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Telephone | 314-394-1660
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Fax | 314-394-1663
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Authorized Official
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Title or Position | MANAGER
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Name | DR. MICHAEL MIMLITZ
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Credential | M.D.
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Telephone | 314-394-1660
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 2017006602
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License Number State | MO
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