Basic Information
Provider Information | |||||||||
NPI: | 1104897727 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RWL, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WENTZVILLE FOOT AND ANKLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 419161 | ||||||||
Address2: |   | ||||||||
City: | CREVE COEUR | ||||||||
State: | MO | ||||||||
PostalCode: | 63141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149890300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 207 CREEKSIDE OFFICE DR | ||||||||
Address2: |   | ||||||||
City: | WENTZVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 633853290 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6363323381 | ||||||||
FaxNumber: | 6363273315 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2006 | ||||||||
LastUpdateDate: | 10/18/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUIKAART | ||||||||
AuthorizedOfficialFirstName: | REED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6363271098 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 2000157310 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.