Provider Demographics
NPI:1578562831
Name:WRYMARK, INC
Entity Type:Organization
Organization Name:WRYMARK, INC
Other - Org Name:RESOURCE O & P
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:L.
Authorized Official - Middle Name:CHURCHILL
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:314-991-3891
Mailing Address - Street 1:11833 WESTLINE INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3312
Mailing Address - Country:US
Mailing Address - Phone:314-991-3891
Mailing Address - Fax:314-991-5720
Practice Address - Street 1:11833 WESTLINE INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3312
Practice Address - Country:US
Practice Address - Phone:314-991-3891
Practice Address - Fax:314-991-5720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO626102008Medicaid