Provider Demographics
NPI:1114165263
Name:NEW BALANCE LAKE ST. LOUIS
Entity Type:Organization
Organization Name:NEW BALANCE LAKE ST. LOUIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PEDORTHIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:636-561-2204
Mailing Address - Street 1:21 MEADOWS CIRCLE DR
Mailing Address - Street 2:SUITE 314
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-4109
Mailing Address - Country:US
Mailing Address - Phone:636-561-2204
Mailing Address - Fax:636-625-2611
Practice Address - Street 1:21 MEADOWS CIRCLE DR
Practice Address - Street 2:SUITE 314
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-4109
Practice Address - Country:US
Practice Address - Phone:636-561-2204
Practice Address - Fax:636-625-2611
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROWN'S ENTERPRISES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013370332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies