Provider Demographics
NPI:1922093632
Name:MIA OF ST CHARLES COUNTY LLC
Entity Type:Organization
Organization Name:MIA OF ST CHARLES COUNTY LLC
Other - Org Name:CLINICAL PET OF ST CHARLES COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-659-1167
Mailing Address - Street 1:PO BOX 868
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0868
Mailing Address - Country:US
Mailing Address - Phone:618-659-1167
Mailing Address - Fax:618-659-1197
Practice Address - Street 1:1475 KISKER RD
Practice Address - Street 2:STE 145
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-8781
Practice Address - Country:US
Practice Address - Phone:636-922-5151
Practice Address - Fax:636-922-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center