MEDICARE: FULL RANGE MOBILE PT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1275274896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL RANGE MOBILE PT, LLC

Provider Business Mailing Address
First Line	:	608 N WINNEBAGO DR
Second Line	:
City	:	LAKE WINNEBAGO
State	:	MO
Zip	:	64034-9419
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 N WINNEBAGO DR
Second Line	:
City	:	LAKE WINNEBAGO
State	:	MO
Zip	:	64034-9419
Country	:	US
Telephone Number	:	913-526-4434
Fax Number	:

Authorized Official
Title or Position	:	OWNER, PHYSICAL THERAPIST
Name	:	MEGAN BECHTOLD
Credential	:	DPT
Telephone Number	:	913-526-4434

Provider Enumeration Date	:	04/06/2022
Last Update Date	:	04/06/2022

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