Healthcare Provider Details

I. General information

NPI: 1194273029
Provider Name (Legal Business Name): RANCE MINER HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 S JEFFERSON AVE
SAINT LOUIS MO
63118-1510
US

IV. Provider business mailing address

2901 S JEFFERSON AVE
SAINT LOUIS MO
63118-1510
US

V. Phone/Fax

Practice location:
  • Phone: 314-323-5143
  • Fax:
Mailing address:
  • Phone: 314-323-5143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number47-3432321
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: