Healthcare Provider Details

I. General information

NPI: 1053046888
Provider Name (Legal Business Name): SPS PRACTICE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2022
Last Update Date: 08/15/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 BLUFF CREEK DR
COLUMBIA MO
65201-3663
US

IV. Provider business mailing address

3220 BLUFF CREEK DR STE 107
COLUMBIA MO
65201-3664
US

V. Phone/Fax

Practice location:
  • Phone: 573-690-6129
  • Fax:
Mailing address:
  • Phone: 573-224-8200
  • Fax: 573-224-8026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LESLIE SHOCK
Title or Position: OWNER
Credential: MD
Phone: 573-224-8200