Healthcare Provider Details

I. General information

NPI: 1144798737
Provider Name (Legal Business Name): FRG RLT HOLDINGS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 SMIZER STATION RD STE 1
FENTON MO
63026-2784
US

IV. Provider business mailing address

PO BOX 790379
SAINT LOUIS MO
63179-0379
US

V. Phone/Fax

Practice location:
  • Phone: 636-861-2125
  • Fax: 636-861-1691
Mailing address:
  • Phone: 314-628-1405
  • Fax: 314-878-4562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY L ELLIOTT
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 314-593-2694