Provider Demographics
NPI:1568596922
Name:WINGHAVEN PEDIATRICS LLC
Entity Type:Organization
Organization Name:WINGHAVEN PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOEFFLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-561-5561
Mailing Address - Street 1:5551 WINGHAVEN BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:O'FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368
Mailing Address - Country:US
Mailing Address - Phone:636-561-5561
Mailing Address - Fax:636-561-5557
Practice Address - Street 1:5551 WINGHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3617
Practice Address - Country:US
Practice Address - Phone:636-561-5561
Practice Address - Fax:636-561-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty