Healthcare Provider Details

I. General information

NPI: 1750720678
Provider Name (Legal Business Name): CHERYL RODAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S KIRKWOOD RD STE 150
KIRKWOOD MO
63122-7251
US

IV. Provider business mailing address

2727 CHINA LAKE DR
SAINT LOUIS MO
63129-5449
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-7554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number106820
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: