Provider Demographics
NPI:1710492228
Name:IDEAL PEDIATRIC WELLNESS, LLC
Entity Type:Organization
Organization Name:IDEAL PEDIATRIC WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSPEH
Authorized Official - Middle Name:
Authorized Official - Last Name:CANGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-270-9355
Mailing Address - Street 1:9788 GERALD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-1708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10007 KENNERLY RD STE C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2179
Practice Address - Country:US
Practice Address - Phone:314-270-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty