Basic Information
| Provider Information | |||||||||
| NPI: | 1972596088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARESTL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 772971 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606770271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148981268 | ||||||||
| FaxNumber: | 8552987184 | ||||||||
| Practice Location | |||||||||
| Address1: | 5471 DR. MARTIN LUTHER KING | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631124265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143675820 | ||||||||
| FaxNumber: | 3143677010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | CLABON | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3143675820 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 500622915 | 05 | MO | MEDICAID |