MEDICARE: SKIWISE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency
3	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003349051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKIWISE LLC

Provider Business Mailing Address
First Line	:	449 N EUCLID AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1642
Country	:	US
Telephone Number	:	314-475-8532
Fax Number	:

Provider Business Practice Location Address
First Line	:	449 N EUCLID AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1642
Country	:	US
Telephone Number	:	314-475-8532
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MISS ALICIA D BUCK
Credential	:
Telephone Number	:	341-475-8532

Provider Enumeration Date	:	04/06/2017
Last Update Date	:	11/23/2021

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Directions to “SKIWISE LLC ” Practice Location

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