Basic Information
| Provider Information | |||||||||
| NPI: | 1740206697 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARESTL HEALTH #3 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOMER G PHILLIPS HEALTH CNTR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2425 WHITTIER ST | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631132950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143713100 | ||||||||
| FaxNumber: | 3145354662 | ||||||||
| Practice Location | |||||||||
| Address1: | 2425 WHITTIER ST | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631132950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143713100 | ||||||||
| FaxNumber: | 3145354662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLABON | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3143675820 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336M0002X | N | Suppliers | Pharmacy | Mail Order Pharmacy | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 3336C0002X | 2005035951 | MO | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2636299 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |