Provider Demographics
NPI:1033487889
Name:ST. LOUIS CENTER FOR PREVENTATIVE AND LONGEVITY MEDICINE
Entity Type:Organization
Organization Name:ST. LOUIS CENTER FOR PREVENTATIVE AND LONGEVITY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLIGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-994-1536
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:777 S NEW BALLAS RD
Practice Address - Street 2:SUITE 200E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8705
Practice Address - Country:US
Practice Address - Phone:413-994-1536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. LOUIS CENTER FOR PREVENTATIVE AND LONGEVITY MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site