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General NPI Number Information
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NPI Number | 1982777413
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY AT WINGHAVEN, LLC
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5551 WINGHAVEN BLVD STE 210
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City | O FALLON
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State | MO
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Zip | 63368-3617
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Country | US
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Telephone | 636-561-4613
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Fax | 636-561-4610
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Provider Business Mailing Address
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Address Line | 5551 WINGHAVEN BLVD STE 210
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City | O FALLON
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State | MO
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Zip | 63368-3617
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Country | US
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Telephone | 636-561-4613
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Fax | 636-561-4610
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Authorized Official
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Title or Position | PHYSICIAN,OWNER
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Name | DR. RACHEL M QUALLEY
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Credential | M.D.
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Telephone | 636-561-4613
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 2004011011
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License Number State | MO
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