Healthcare Provider Details

I. General information

NPI: 1629590955
Provider Name (Legal Business Name): JUDICE CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SHALLOWCREEK VW
BALLWIN MO
63021-6618
US

IV. Provider business mailing address

700 SHALLOWCREEK VW
BALLWIN MO
63021-6618
US

V. Phone/Fax

Practice location:
  • Phone: 225-505-6659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2014027053
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. GREGORY CHARLES JUDICE
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 225-505-6659