MEDICARE: MONICA ANNE RAINE PTA

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	225200000X	Physical Therapy Assistant	1811	AR
2	225200000X	Physical Therapy Assistant	2014012166	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598810376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONICA ANNE RAINE PTA

Provider Business Mailing Address
First Line	:	1212 HOLGATE DR
Second Line	:
City	:	MANCHESTER
State	:	MO
Zip	:	63021-6868
Country	:	US
Telephone Number	:	870-404-3944
Fax Number	:

Provider Business Practice Location Address
First Line	:	11960 WESTLINE INDUSTRIAL DR STE 201
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3209
Country	:	US
Telephone Number	:	870-404-3944
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/22/2014

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