Provider Demographics
NPI:1447494133
Name:THE YOUTHFUL BODY MEDICAL SPA
Entity type:Organization
Organization Name:THE YOUTHFUL BODY MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:FALCONER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-692-2639
Mailing Address - Street 1:69 BELLERIVE ACRES
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4330
Mailing Address - Country:US
Mailing Address - Phone:314-495-2700
Mailing Address - Fax:314-389-6023
Practice Address - Street 1:10287 CLAYTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-1172
Practice Address - Country:US
Practice Address - Phone:314-692-2639
Practice Address - Fax:314-692-2649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115456261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty