Healthcare Provider Details

I. General information

NPI: 1871430124
Provider Name (Legal Business Name): CLERIC RAY GLADNEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 SUNSET LN
O FALLON MO
63366-2278
US

IV. Provider business mailing address

716 SUNSET LN 716 SUNSET LN
O FALLON MO
63366-2278
US

V. Phone/Fax

Practice location:
  • Phone: 314-610-3159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: