Healthcare Provider Details

I. General information

NPI: 1770824062
Provider Name (Legal Business Name): ACCESS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3522 PALMYRA RD SUITE A
HANNIBAL MO
63401-2212
US

IV. Provider business mailing address

3522 PALMYRA RD SUITE A
HANNIBAL MO
63401-2212
US

V. Phone/Fax

Practice location:
  • Phone: 573-248-8076
  • Fax: 573-248-8082
Mailing address:
  • Phone: 573-248-8076
  • Fax: 573-248-8082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2006034980
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2006034980
License Number StateMO

VIII. Authorized Official

Name: TOM RODEGHERO
Title or Position: PRESIDENT, OWNER
Credential: DPT
Phone: 573-822-5731