MEDICARE: LENNY KAGAN

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		MO

General Provider Information

NPI Number	:	1609642107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LENNY KAGAN

Provider Business Mailing Address
First Line	:	9715 OLIVE BLVD STE C
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-3004
Country	:	US
Telephone Number	:	314-913-9990
Fax Number	:	314-755-1030

Provider Business Practice Location Address
First Line	:	9715 OLIVE BLVD STE C
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-3004
Country	:	US
Telephone Number	:	314-913-9990
Fax Number	:	314-755-1030

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

Provider Enumeration Date	:	11/27/2023
Last Update Date	:	11/27/2023

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Directions to “ LENNY KAGAN ” Practice Location

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