Provider Demographics
NPI:1861367203
Name:THE AMTAG GROUP LLC
Entity type:Organization
Organization Name:THE AMTAG GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIBONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-755-9717
Mailing Address - Street 1:1616 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-3107
Mailing Address - Country:US
Mailing Address - Phone:314-755-9717
Mailing Address - Fax:314-755-9717
Practice Address - Street 1:1616 N 18TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-3107
Practice Address - Country:US
Practice Address - Phone:314-755-9717
Practice Address - Fax:314-755-9717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-07
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty