Healthcare Provider Details

I. General information

NPI: 1588896674
Provider Name (Legal Business Name): TYBAR MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2009
Last Update Date: 08/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 DOWNEY TERRACE DR
ELLISVILLE MO
63011-1996
US

IV. Provider business mailing address

2295 DOWNEY TERRACE DR
ELLISVILLE MO
63011-1996
US

V. Phone/Fax

Practice location:
  • Phone: 636-273-9913
  • Fax: 636-273-9913
Mailing address:
  • Phone: 636-273-9913
  • Fax: 636-273-9913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberLC0639198
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberLC0639198
License Number StateMO

VIII. Authorized Official

Name: TODD SPIEGEL
Title or Position: PRESIDENT
Credential:
Phone: 636-273-9913