Healthcare Provider Details

I. General information

NPI: 1013309178
Provider Name (Legal Business Name): DEMETRICES CARTER JR. RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11960 WESTLINE INDUSTRIAL DR
SAINT LOUIS MO
63146-3209
US

IV. Provider business mailing address

11960 WESTLINE INDUSTRIAL DR
SAINT LOUIS MO
63146-3209
US

V. Phone/Fax

Practice location:
  • Phone: 314-275-7444
  • Fax:
Mailing address:
  • Phone: 314-275-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number2009035077
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number194.008539
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: