Provider Demographics
NPI:1407314263
Name:INSTITUTE OF PERSONALIZED MEDICINE LLC
Entity Type:Organization
Organization Name:INSTITUTE OF PERSONALIZED MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-546-6072
Mailing Address - Street 1:7721 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1301
Mailing Address - Country:US
Mailing Address - Phone:314-546-6072
Mailing Address - Fax:314-569-4961
Practice Address - Street 1:7721 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63117-1301
Practice Address - Country:US
Practice Address - Phone:314-546-6072
Practice Address - Fax:314-569-4961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty