Provider Demographics
NPI:1538591227
Name:FAMILIES 1ST OF DESOTO, LLC.
Entity type:Organization
Organization Name:FAMILIES 1ST OF DESOTO, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:HEADY-FENWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-337-7800
Mailing Address - Street 1:127 W PRATT ST
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-2107
Mailing Address - Country:US
Mailing Address - Phone:636-337-7800
Mailing Address - Fax:
Practice Address - Street 1:127 W PRATT ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2107
Practice Address - Country:US
Practice Address - Phone:636-337-7800
Practice Address - Fax:636-337-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-05
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102003207Q00000X
MO144688363LA2200X
MO2010037937363LF0000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty