Healthcare Provider Details

I. General information

NPI: 1093676405
Provider Name (Legal Business Name): RYAN WILLIAM DYKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 N GRAND BLVD
SAINT LOUIS MO
63103
US

IV. Provider business mailing address

6801 BONNIE AVE
SAINT LOUIS MO
63123-3236
US

V. Phone/Fax

Practice location:
  • Phone: 800-758-3678
  • Fax:
Mailing address:
  • Phone: 314-203-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number330027
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: