Basic Information
| Provider Information | |||||||||
| NPI: | 1730221664 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARESTL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5471 DR MARTIN LUTHER KING DRIVE | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631124265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143675820 | ||||||||
| FaxNumber: | 3143677010 | ||||||||
| Practice Location | |||||||||
| Address1: | 2425 WHITTIER | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143713100 | ||||||||
| FaxNumber: | 3142898718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | CLABON | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3143675820 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 26D1039187 | MO | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 507523702 | 05 | MO | MEDICAID |