Individual
KEVIN JAMES LICKENBROCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2900 LEMAY FERRY RD, SUITE 100, SAINT LOUIS, MO 63125-3900
(314) 543-5294
Mailing address
1159 ALBANY CT, SAINT LOUIS, MO 63119-4733
(314) 961-4098
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
100453
MO
Other
Enumeration date
03/29/2007
Last updated
07/08/2007
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