Provider Demographics
NPI:1144505447
Name:SI03, INC.
Entity type:Organization
Organization Name:SI03, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:FANGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-388-2301
Mailing Address - Street 1:PO BOX 1715
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702
Mailing Address - Country:US
Mailing Address - Phone:573-388-2301
Mailing Address - Fax:573-388-2302
Practice Address - Street 1:4711 NASH ROAD
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:MO
Practice Address - Zip Code:63780
Practice Address - Country:US
Practice Address - Phone:573-388-2301
Practice Address - Fax:573-388-2308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335G00000XSuppliersMedical Foods Supplier