MEDICARE: ST. LOUIS RENAL CARE LLC. PRINCE HALL

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1679776124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. LOUIS RENAL CARE LLC. PRINCE HALL

Provider Business Mailing Address
First Line	:	4411 N NEWSTEAD AVE
Second Line	:	2ND FLOOR DIALYSIS
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-2534
Country	:	US
Telephone Number	:	314-879-6278
Fax Number	:	314-381-1685

Provider Business Practice Location Address
First Line	:	4411 N NEWSTEAD AVE
Second Line	:	2ND FLOOR DIALYSIS
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-2534
Country	:	US
Telephone Number	:	314-879-6278
Fax Number	:	314-381-1685

Authorized Official
Title or Position	:	AREA MANAGER
Name	:	MISS GERDI WINKLER
Credential	:	RN CNN
Telephone Number	:	314-920-6007

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	08/22/2020

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