Provider Demographics
NPI:1992305007
Name:PROFICIENT WELLNESS LLC
Entity type:Organization
Organization Name:PROFICIENT WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-447-0725
Mailing Address - Street 1:2050 WOODSON RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5644
Mailing Address - Country:US
Mailing Address - Phone:314-447-0725
Mailing Address - Fax:
Practice Address - Street 1:2050 WOODSON RD
Practice Address - Street 2:
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-5644
Practice Address - Country:US
Practice Address - Phone:314-447-0725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty