MEDICARE: MARIE ANGELIQUE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1134565971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIE ANGELIQUE

Provider Business Mailing Address
First Line	:	220 N MAIN ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-2829
Country	:	US
Telephone Number	:	636-949-2348
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 N MAIN ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-2829
Country	:	US
Telephone Number	:	636-949-2348
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NAOMI FITZPATRICK
Credential	:
Telephone Number	:	636-949-2348

Provider Enumeration Date	:	05/20/2013
Last Update Date	:	09/16/2014

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