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General NPI Number Information
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NPI Number | 1912603507
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Entity Type | Organization
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Legal Business Name | FREDERICK CUSTOMEYEZ IN ST. LOUIS
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Dates
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Enumeration Date | 02/06/2023
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Last Update Date | 07/03/2025
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Provider Practice Location Address
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Address Line | 1834 CRAIG RD
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City | SAINT LOUIS
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State | MO
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Zip | 63146-4712
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Country | US
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Telephone | 401-584-3939
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Fax |
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Provider Business Mailing Address
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Address Line | 9278 PARADISE DR
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32413-9625
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Country | US
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Telephone | 401-584-3939
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Fax | 216-678-9186
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Authorized Official
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Title or Position | OWNER
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Name | MELISSA FREDERICK
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Credential |
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Telephone | 401-584-3939
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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