Healthcare Provider Details

I. General information

NPI: 1689197006
Provider Name (Legal Business Name): AEGIS GROUP PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

107 BERNARD DR
BELTON MO
64012-6185
US

IV. Provider business mailing address

1000 FIANNA WAY # MD5740
FORT SMITH AR
72919-9008
US

V. Phone/Fax

Practice location:
  • Phone: 800-444-6845
  • Fax: 479-478-2852
Mailing address:
  • Phone: 479-201-6089
  • Fax: 479-935-2970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL MCOLVIN
Title or Position: VICE PRESIDENT - FINANCE
Credential:
Phone: 479-201-6100