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General NPI Number Information
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NPI Number | 1427422336
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Entity Type | Organization
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Legal Business Name | NORTHLIGHT DEVELOPMENT LP
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Dates
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Enumeration Date | 11/17/2015
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Last Update Date | 11/17/2015
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Provider Practice Location Address
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Address Line | 3414 HAWTHORNE BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63104-1623
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Country | US
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Telephone | 314-773-4074
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Fax |
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Provider Business Mailing Address
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Address Line | 3414 HAWTHORNE BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63104-1623
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Country | US
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Telephone | 314-773-4074
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH R SMITH JR.
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Credential | MD
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Telephone | 314-773-4074
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 26655
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License Number State | MO
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