MEDICARE: CLIFFE OBANNER

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	172A00000X	Driver
2	342000000X	Transportation Network Company

General Provider Information

NPI Number	:	1356084206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLIFFE OBANNER

Provider Business Mailing Address
First Line	:	14600 MONDOUBLEAU LN
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63034-2314
Country	:	US
Telephone Number	:	202-378-4864
Fax Number	:

Provider Business Practice Location Address
First Line	:	14600 MONDOUBLEAU LN
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63034-2314
Country	:	US
Telephone Number	:	202-378-4864
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2022
Last Update Date	:	04/19/2022

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Directions to “ CLIFFE OBANNER ” Practice Location

Language	Start Address	Practice Location

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