=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588896674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TYBAR MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2009
-----------------------------------------------------
Last Update Date | 08/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2295 DOWNEY TERRACE DR
-----------------------------------------------------
City | ELLISVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63011-1996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-273-9913
-----------------------------------------------------
Fax | 636-273-9913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2295 DOWNEY TERRACE DR
-----------------------------------------------------
City | ELLISVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63011-1996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-273-9913
-----------------------------------------------------
Fax | 636-273-9913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TODD SPIEGEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 636-273-9913
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | LC0639198
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | LC0639198
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------