MEDICARE: ANITA LYNN HOLBROOK

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	1744P3200X	Prosthetics Case Management	088456	MO

General Provider Information

NPI Number	:	1710504576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANITA LYNN HOLBROOK

Provider Business Mailing Address
First Line	:	4603 NATURAL BRIDGE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-1922
Country	:	US
Telephone Number	:	314-833-4603
Fax Number	:

Provider Business Practice Location Address
First Line	:	4603 NATURAL BRIDGE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-1922
Country	:	US
Telephone Number	:	314-833-4603
Fax Number	:

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

Provider Enumeration Date	:	06/28/2020
Last Update Date	:	06/28/2020

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