MEDICARE: EDGAR DEJUAN HARRIS

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	172V00000X	Community Health Worker	0000000000000	MO

General Provider Information

NPI Number	:	1821417916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDGAR DEJUAN HARRIS

Provider Business Mailing Address
First Line	:	1721 HONEYBROOK LN
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1468
Country	:	US
Telephone Number	:	314-484-0405
Fax Number	:

Provider Business Practice Location Address
First Line	:	1721 HONEYBROOK LN
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1468
Country	:	US
Telephone Number	:	314-484-0405
Fax Number	:

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

Provider Enumeration Date	:	04/16/2014
Last Update Date	:	04/16/2014

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