Provider Demographics
NPI:1629135108
Name:AFFIRMED FAMILY HEALTHCARE, LLC
Entity Type:Organization
Organization Name:AFFIRMED FAMILY HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURAIN
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-395-3575
Mailing Address - Street 1:3645 OAKMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4906
Mailing Address - Country:US
Mailing Address - Phone:314-383-0330
Mailing Address - Fax:314-383-0510
Practice Address - Street 1:3645 OAKMOUNT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4906
Practice Address - Country:US
Practice Address - Phone:314-383-0330
Practice Address - Fax:314-383-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF78404Medicare UPIN