Healthcare Provider Details

I. General information

NPI: 1952620700
Provider Name (Legal Business Name): MTS-DES PERES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12360 MANCHESTER RD SUITE 150
DES PERES MO
63131-4312
US

IV. Provider business mailing address

17300 N OUTER 40 RD SUITE 205
CHESTERFIELD MO
63005-1364
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-2273
  • Fax: 314-966-8855
Mailing address:
  • Phone: 636-728-1777
  • Fax: 636-728-1793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL GORMAN
Title or Position: OWNER
Credential: PT MOMT DMT
Phone: 636-728-1777