Provider Demographics
NPI:1275956286
Name:DIRECTOR
Entity Type:Organization
Organization Name:DIRECTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-825-2084
Mailing Address - Street 1:1112 WILD PLUM DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303-1208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 N EUCLID AVE STE 302
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1690
Practice Address - Country:US
Practice Address - Phone:314-825-2084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health