Healthcare Provider Details

I. General information

NPI: 1700562444
Provider Name (Legal Business Name): MR. CEALUS RUDEN MANNING III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6763 PAGE AVE
SAINT LOUIS MO
63133-1635
US

IV. Provider business mailing address

6763 PAGE AVE
SAINT LOUIS MO
63133-1635
US

V. Phone/Fax

Practice location:
  • Phone: 314-379-9085
  • Fax:
Mailing address:
  • Phone: 314-379-9085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: