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General NPI Number Information
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NPI Number | 1346630803
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Entity Type | Organization
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Legal Business Name | AGM IOP/PHP, LLC
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Dates
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Enumeration Date | 02/04/2015
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Last Update Date | 04/08/2019
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Provider Practice Location Address
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Address Line | 10199 WOODFIELD LN
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City | OLIVETTE
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State | MO
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Zip | 63132-2922
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Country | US
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Telephone | 314-282-2517
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Fax | 314-845-2798
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Provider Business Mailing Address
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Address Line | 10199 WOODFIELD LN
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City | OLIVETTE
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State | MO
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Zip | 63132-2922
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Country | US
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Telephone | 314-222-0602
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Fax | 314-675-6681
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Authorized Official
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Title or Position | OWNER
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Name | DR. FRANCO SICURO
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Credential | M.D.
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Telephone | 314-222-0602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | LC001426559
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | LC001426559
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License Number State | MO
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