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General NPI Number Information
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NPI Number | 1770027898
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Entity Type | Organization
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Legal Business Name | BGLG22, LLC
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Dates
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Enumeration Date | 12/08/2016
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Last Update Date | 12/08/2016
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Provider Practice Location Address
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Address Line | 1414 SUNBURST DR
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City | O FALLON
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State | MO
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Zip | 63366-3490
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Country | US
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Telephone | 314-409-4292
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Fax | 636-527-5835
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Provider Business Mailing Address
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Address Line | 1414 SUNBURST DR
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City | O FALLON
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State | MO
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Zip | 63366-3490
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Country | US
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Telephone | 314-409-4292
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Fax | 636-527-5835
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. BRIAN R RANDOLPH
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Credential |
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Telephone | 314-409-4292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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