Healthcare Provider Details

I. General information

NPI: 1568460368
Provider Name (Legal Business Name): ESB MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 CHIPPEWA ST SUITE 219
SAINT LOUIS MO
63109-2538
US

IV. Provider business mailing address

6651 CHIPPEWA ST SUITE 219
SAINT LOUIS MO
63109-2538
US

V. Phone/Fax

Practice location:
  • Phone: 314-646-0980
  • Fax: 314-646-0613
Mailing address:
  • Phone: 314-646-0980
  • Fax: 314-646-0613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number2003022170
License Number StateMO

VIII. Authorized Official

Name: MR. RANDALL RATAY
Title or Position: PRESIDENT
Credential:
Phone: 314-646-0980