Provider Demographics
NPI:1407970288
Name:ST. LOUIS CENTER OF PREVENTITIVE & LONGEVITY MEDICINE, LLC
Entity Type:Organization
Organization Name:ST. LOUIS CENTER OF PREVENTITIVE & LONGEVITY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLIGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-721-0666
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN CREDENTIALING DEPAT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:1034 S BRENTWOOD BLVD
Practice Address - Street 2:SUITE 1060
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1223
Practice Address - Country:US
Practice Address - Phone:314-721-0666
Practice Address - Fax:314-727-9612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD102881207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty