MEDICARE: VALLIE JO ROGERS PT

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	107429	MO

General Provider Information

NPI Number	:	1952314957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VALLIE JO ROGERS PT

Provider Business Mailing Address
First Line	:	PO BOX 702
Second Line	:
City	:	MOUNTAIN GROVE
State	:	MO
Zip	:	65711-0702
Country	:	US
Telephone Number	:	417-926-0333
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 N MAIN ST
Second Line	:	SUITE 1
City	:	MOUNTAIN GROVE
State	:	MO
Zip	:	65711-1025
Country	:	US
Telephone Number	:	417-926-5699
Fax Number	:	417-926-5703

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/08/2007

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