Healthcare Provider Details

I. General information

NPI: 1578771663
Provider Name (Legal Business Name): RANDY R RICHTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3437 CAROLINE ST
SAINT LOUIS MO
63104-1111
US

IV. Provider business mailing address

411 LINDENWOOD DR
TROY IL
62294-1065
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8545
  • Fax:
Mailing address:
  • Phone: 618-667-2994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01095
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: