Provider Demographics
NPI:1699824987
Name:HEALTHMARK GRAVOIS LLC
Entity Type:Organization
Organization Name:HEALTHMARK GRAVOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:EKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-446-0050
Mailing Address - Street 1:11600 MANCHESTER RD STE 1O1
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-4691
Mailing Address - Country:US
Mailing Address - Phone:314-446-0050
Mailing Address - Fax:314-822-8476
Practice Address - Street 1:9701 LANDMARK PARKWAY DR STE 102
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1665
Practice Address - Country:US
Practice Address - Phone:314-446-0050
Practice Address - Fax:314-822-8476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical