Healthcare Provider Details

I. General information

NPI: 1497539779
Provider Name (Legal Business Name): MOXIE PELVIC HEALTH AND WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 EXECUTIVE PLAZA CT
MARYVILLE IL
62062-5838
US

IV. Provider business mailing address

1830 BINNEY STATION RD
STAUNTON IL
62088-4425
US

V. Phone/Fax

Practice location:
  • Phone: 618-226-8277
  • Fax:
Mailing address:
  • Phone: 217-320-3707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMBER D DA GAMA ROSE
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: DPT
Phone: 217-320-3707