1770514879 NPI number — SPORTS AND PHYSICAL THERAPY CENTER

Table of content: (NPI 1770514879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770514879 NPI number — SPORTS AND PHYSICAL THERAPY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS AND PHYSICAL THERAPY CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SPTC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770514879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 N CENTRAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUREKA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63025-1826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-938-4065
Provider Business Mailing Address Fax Number:
636-938-4067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
322 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63025-1826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-938-4065
Provider Business Practice Location Address Fax Number:
636-938-4067
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
QUINN
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
636-938-4065

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2001005492 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11299 . This is a "ESSENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00158791 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 683038 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 227075 . This is a "GHP ADVANTRA CMR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6400737 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 193453 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 610149300 . This is a "DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7889614 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com