Provider Demographics
NPI:1871196758
Name:NEILL, MICHAEL CALVIN JR
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CALVIN
Last Name:NEILL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19728 TOWNSHIP LINE RD
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383-4448
Mailing Address - Country:US
Mailing Address - Phone:636-279-4658
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1366
Practice Address - Country:US
Practice Address - Phone:636-625-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO155183376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty