1700138377 NPI number — ADVANCED SPORTS AND REHAB, LLC

Table of content: (NPI 1700138377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700138377 NPI number — ADVANCED SPORTS AND REHAB, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SPORTS AND REHAB, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1700138377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1899 N WESTWOOD BLVD
Provider Second Line Business Mailing Address:
SUITE C, PMB 113
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63901-2833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-785-3966
Provider Business Mailing Address Fax Number:
573-785-3966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 S MADISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALDEN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63863-2462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-276-4999
Provider Business Practice Location Address Fax Number:
573-276-5084
Provider Enumeration Date:
10/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KEELING
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
DENNIS
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
573-718-2699

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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