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General NPI Number Information
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NPI Number | 1639500192
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Entity Type | Organization
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Legal Business Name | PEDIATRIC NEURODEVELOPMENTAL CENTER LLC
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Dates
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Enumeration Date | 12/10/2013
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Last Update Date | 12/10/2013
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Provider Practice Location Address
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Address Line | 17300 N OUTER 40 RD SUITE 205
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City | CHESTERFIELD
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State | MO
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Zip | 63005-1364
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Country | US
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Telephone | 636-778-9212
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Fax |
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Provider Business Mailing Address
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Address Line | 17300 N OUTER 40 RD SUITE 205
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City | CHESTERFIELD
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State | MO
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Zip | 63005-1364
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Country | US
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Telephone | 636-778-9212
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED REP/ OWNER/ MD
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Name | DR. AVI E. DOMNITZ-GEBET
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Credential | D.O.
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Telephone | 636-778-9212
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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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