Healthcare Provider Details

I. General information

NPI: 1841477288
Provider Name (Legal Business Name): DUSTIN STORCK D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 FORTUNE BLVD
SHILOH IL
62269-7358
US

IV. Provider business mailing address

RR 2 BOX 36
FARINA IL
62838-9421
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-6988
  • Fax:
Mailing address:
  • Phone: 618-795-0667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number70015924
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2007034391
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2007034391
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: