Healthcare Provider Details

I. General information

NPI: 1023556156
Provider Name (Legal Business Name): MICHAEL RYAN CAVALIER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

7 TRENT PARK CT
O FALLON MO
63368-8093
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2011038834
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: