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General NPI Number Information
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NPI Number | 1568596922
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Entity Type | Organization
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Legal Business Name | WINGHAVEN PEDIATRICS LLC
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 04/22/2009
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Provider Practice Location Address
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Address Line | 5551 WINGHAVEN BLVD
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City | O FALLON
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State | MO
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Zip | 63368-3617
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Country | US
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Telephone | 636-561-5561
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Fax | 636-561-5557
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Provider Business Mailing Address
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Address Line | 5551 WINGHAVEN BLVD SUITE 240
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City | O'FALLON
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State | MO
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Zip | 63368
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Country | US
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Telephone | 636-561-5561
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Fax | 636-561-5557
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | HOLLY LOEFFLER
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Credential |
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Telephone | 636-561-5561
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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