1952362352 NPI number — ACTIVE CARE PHYSICAL THERAPY & SPINE CENTER, LLC

Table of content: XENIA DEANS (NPI 1407200587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952362352 NPI number — ACTIVE CARE PHYSICAL THERAPY & SPINE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE CARE PHYSICAL THERAPY & SPINE CENTER, 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:
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:
1952362352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5497A HIGHWAY 54
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSAGE BEACH
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65065-3026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-302-1288
Provider Business Mailing Address Fax Number:
573-302-1384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5497A HIGHWAY 54
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSAGE BEACH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65065-3026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-302-1288
Provider Business Practice Location Address Fax Number:
573-302-1384
Provider Enumeration Date:
03/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLAUGHRY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
573-302-1288

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  102576 , 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: 189021 . This is a "BLUE CROSS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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