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General NPI Number Information
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NPI Number | 1851629356
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Entity Type | Organization
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Legal Business Name | LIFE LINE SURGICAL SERVICES LLC
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Dates
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Enumeration Date | 11/23/2009
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Last Update Date | 02/07/2023
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Provider Practice Location Address
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Address Line | 10004 KENNERLY RD SUITE 330-A
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City | SAINT LOUIS
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State | MO
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Zip | 63128-2141
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Country | US
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Telephone | 314-718-9947
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Fax | 314-718-9947
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Provider Business Mailing Address
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Address Line | 10004 KENNERLY RD SUITE 330-A
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City | SAINT LOUIS
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State | MO
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Zip | 63128-2141
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Country | US
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Telephone | 314-718-9947
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Fax | 314-718-9947
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Authorized Official
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Title or Position | NURSE/MANAGER
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Name | MS. DELLA ARIDGE
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Credential | NP
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Telephone | 314-591-1125
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 33400
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License Number State | MO
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