Provider Demographics
NPI:1306083175
Name:STL MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:STL MEDICAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GUPTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-667-6161
Mailing Address - Street 1:305 KEAWE ST
Mailing Address - Street 2:SUITE 507
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-2734
Mailing Address - Country:US
Mailing Address - Phone:808-667-6161
Mailing Address - Fax:808-667-6166
Practice Address - Street 1:305 KEAWE ST
Practice Address - Street 2:SUITE 507
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-2734
Practice Address - Country:US
Practice Address - Phone:808-667-6161
Practice Address - Fax:808-667-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-13784261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care