Provider Demographics
NPI:1376802678
Name:COMPREHENSIVE INDEPENDENT GOALS INC ST. LOUIS CONSUMER DIRECTED SERVIC
Entity Type:Organization
Organization Name:COMPREHENSIVE INDEPENDENT GOALS INC ST. LOUIS CONSUMER DIRECTED SERVIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES./C. F. O.
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:MAX
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-361-7337
Mailing Address - Street 1:PO BOX 66037
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70896-6037
Mailing Address - Country:US
Mailing Address - Phone:225-926-5190
Mailing Address - Fax:225-926-6964
Practice Address - Street 1:40 N KINGSHIGHWAY BLVD
Practice Address - Street 2:SUITE - 6
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1378
Practice Address - Country:US
Practice Address - Phone:314-361-7337
Practice Address - Fax:314-361-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1157384Medicaid
LA1173835Medicaid
LA1642649Medicaid
MO1104137041Medicaid
LA1157392Medicaid