Provider Demographics
NPI:1376768796
Name:MECKLENBURG, DAN
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:MECKLENBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4202
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63006-4202
Mailing Address - Country:US
Mailing Address - Phone:314-871-9306
Mailing Address - Fax:
Practice Address - Street 1:2144 COURTLEIGH LN
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-7623
Practice Address - Country:US
Practice Address - Phone:314-871-9306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4096730001Medicare ID - Type Unspecified