=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881131993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEANDRE HORNE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2017
-----------------------------------------------------
Last Update Date | 01/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3159 FEE FEE RD STE 203
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63044-3299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-261-6126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3159 FEE FEE RD STE 203
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63044-3299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-261-6126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------