Healthcare Provider Details

I. General information

NPI: 1477658631
Provider Name (Legal Business Name): MAURY ALLEN P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CLUB VILLAGE DR SUITE 103
COLUMBIA MO
65203-4409
US

IV. Provider business mailing address

1100 CLUB VILLAGE DR SUITE 103
COLUMBIA MO
65203-4409
US

V. Phone/Fax

Practice location:
  • Phone: 573-256-2777
  • Fax: 573-256-2764
Mailing address:
  • Phone: 573-256-2777
  • Fax: 573-256-2764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2000174328
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: