Provider Demographics
NPI:1285872614
Name:NEW BALANCE ST.LOUIS
Entity type:Organization
Organization Name:NEW BALANCE ST.LOUIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PEDORTHIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:314-872-2929
Mailing Address - Street 1:11633 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7001
Mailing Address - Country:US
Mailing Address - Phone:314-872-2929
Mailing Address - Fax:314-872-2926
Practice Address - Street 1:11633 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7001
Practice Address - Country:US
Practice Address - Phone:314-872-2929
Practice Address - Fax:314-872-2926
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROWN'S ENTERPRISES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-22
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOB00029005332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0510770004Medicare NSC