Healthcare Provider Details

I. General information

NPI: 1134523467
Provider Name (Legal Business Name): JAMES GAVEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BOGIE HILLS DR
COLUMBIA MO
65201-2832
US

IV. Provider business mailing address

101 BOGIE HILLS DR
COLUMBIA MO
65201-2832
US

V. Phone/Fax

Practice location:
  • Phone: 573-999-4925
  • Fax:
Mailing address:
  • Phone: 573-999-4925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2014006796
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: