Provider Demographics
NPI:1003349051
Name:SKIWISE LLC
Entity Type:Organization
Organization Name:SKIWISE LLC
Other - Org Name:SKIWISE HEALTH AND WELLNESS SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:341-475-8532
Mailing Address - Street 1:449 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1642
Mailing Address - Country:US
Mailing Address - Phone:314-475-8532
Mailing Address - Fax:
Practice Address - Street 1:449 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1642
Practice Address - Country:US
Practice Address - Phone:314-475-8532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490051600Medicaid
MO500099408Medicaid