Healthcare Provider Details

I. General information

NPI: 1427168087
Provider Name (Legal Business Name): ROBERT CZARNECKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N KEENE ST SUITE 101
COLUMBIA MO
65201-6986
US

IV. Provider business mailing address

215 HAAF DR
JEFFERSON CITY MO
65101-4411
US

V. Phone/Fax

Practice location:
  • Phone: 573-874-0001
  • Fax:
Mailing address:
  • Phone: 573-874-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number20050307589
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: