Basic Information
Provider Information | |||||||||
NPI: | 1841522265 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SIGNATURE HEALTH SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12639 OLD TESSON RD | ||||||||
Address2: | SUITE 115 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631282786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3148428655 | ||||||||
FaxNumber: | 3148494423 | ||||||||
Practice Location | |||||||||
Address1: | 606 MAPLE VALLEY DR | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | MO | ||||||||
PostalCode: | 636401976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737567779 | ||||||||
FaxNumber: | 6369337403 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2010 | ||||||||
LastUpdateDate: | 02/10/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VEST | ||||||||
AuthorizedOfficialFirstName: | JAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3148490311 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 501357701 | 05 | MO |   | MEDICAID |