Provider Demographics
NPI:1003392697
Name:AFFINIA HEALTHCARE
Entity Type:Organization
Organization Name:AFFINIA HEALTHCARE
Other - Org Name:SALVATION ARMY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CORINTHIA
Authorized Official - Middle Name:DARCEL
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-814-8531
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63188-0551
Mailing Address - Country:US
Mailing Address - Phone:314-898-1700
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:2900 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1306
Practice Address - Country:US
Practice Address - Phone:314-898-1700
Practice Address - Fax:314-814-8542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========OtherTIN