Provider Demographics
NPI:1679776124
Name:ST. LOUIS RENAL CARE LLC. PRINCE HALL
Entity Type:Organization
Organization Name:ST. LOUIS RENAL CARE LLC. PRINCE HALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AREA MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:GERDI
Authorized Official - Middle Name:
Authorized Official - Last Name:WINKLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN CNN
Authorized Official - Phone:314-920-6007
Mailing Address - Street 1:4411 N NEWSTEAD AVE
Mailing Address - Street 2:2ND FLOOR DIALYSIS
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-2534
Mailing Address - Country:US
Mailing Address - Phone:314-879-6278
Mailing Address - Fax:314-381-1685
Practice Address - Street 1:4411 N NEWSTEAD AVE
Practice Address - Street 2:2ND FLOOR DIALYSIS
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-2534
Practice Address - Country:US
Practice Address - Phone:314-879-6278
Practice Address - Fax:314-381-1685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
262598Medicare ID - Type Unspecified