Healthcare Provider Details

I. General information

NPI: 1063635647
Provider Name (Legal Business Name): JUSTIN TATE RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11701 BORMAN DR SUITE 280
SAINT LOUIS MO
63146-4100
US

IV. Provider business mailing address

2519 S 9TH ST APT A
SAINT LOUIS MO
63104-4710
US

V. Phone/Fax

Practice location:
  • Phone: 314-983-9555
  • Fax: 314-983-9444
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279G1100X
TaxonomyGeneral Care Registered Respiratory Therapist
License Number2003017948
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: