MEDICARE: EILEEN D KINSELLA LMT, NCBTMB

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	174400000X	Specialist	2001027022	MO
2	174400000X	Specialist	004180-00	MO

General Provider Information

NPI Number	:	1780924332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EILEEN D KINSELLA LMT, NCBTMB

Provider Business Mailing Address
First Line	:	6816 SCANLAN AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2539
Country	:	US
Telephone Number	:	314-608-3862
Fax Number	:

Provider Business Practice Location Address
First Line	:	6816 SCANLAN AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2539
Country	:	US
Telephone Number	:	314-608-3862
Fax Number	:

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

Provider Enumeration Date	:	02/19/2013
Last Update Date	:	02/19/2013

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