Healthcare Provider Details

I. General information

NPI: 1528379260
Provider Name (Legal Business Name): ROGER ALAN MAYLE LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E MILL ST
HUMANSVILLE MO
65674-8507
US

IV. Provider business mailing address

202 E MILL ST
HUMANSVILLE MO
65674
US

V. Phone/Fax

Practice location:
  • Phone: 417-754-1601
  • Fax: 417-754-1602
Mailing address:
  • Phone: 417-754-1601
  • Fax: 417-754-1602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number115385
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: