=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609526482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALL SMILEZ LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2022
-----------------------------------------------------
Last Update Date | 04/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4144 LINDELL BLVD STE 203
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-532-4330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4144 LINDELL BLVD STE 203
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-532-4330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARKEYTA STITTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-532-4330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------