Healthcare Provider Details

I. General information

NPI: 1801306980
Provider Name (Legal Business Name): MR. DONOVAN RANELL HYGRADE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

IV. Provider business mailing address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3700
  • Fax:
Mailing address:
  • Phone: 314-206-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: