MEDICARE: LICE BUSTERS ST. LOUIS LLC

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1639609209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LICE BUSTERS ST. LOUIS LLC

Provider Business Mailing Address
First Line	:	7923 BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2703
Country	:	US
Telephone Number	:	314-329-5423
Fax Number	:

Provider Business Practice Location Address
First Line	:	7923 BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2703
Country	:	US
Telephone Number	:	314-329-5423
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH LUTZ
Credential	:
Telephone Number	:	314-973-9837

Provider Enumeration Date	:	06/15/2017
Last Update Date	:	07/21/2022

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