Provider Demographics
NPI:1407904139
Name:MICROVAS WELLNESS CENTER
Entity Type:Organization
Organization Name:MICROVAS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-822-1345
Mailing Address - Street 1:11693 MANCHESTER RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-4613
Mailing Address - Country:US
Mailing Address - Phone:314-822-1345
Mailing Address - Fax:314-822-1082
Practice Address - Street 1:11693 MANCHESTER RD
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-4613
Practice Address - Country:US
Practice Address - Phone:314-822-1345
Practice Address - Fax:314-822-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========OtherTAX ID