Healthcare Provider Details

I. General information

NPI: 1720971658
Provider Name (Legal Business Name): MARTINA RAY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

4 OXBOW RD
SAINT PETERS MO
63376-1504
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6382
  • Fax:
Mailing address:
  • Phone: 618-520-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2012036540
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: