Healthcare Provider Details

I. General information

NPI: 1376149393
Provider Name (Legal Business Name): ANODYNE OF MANCHESTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2020
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BRITTANY PKWY
MANCHESTER MO
63011-4325
US

IV. Provider business mailing address

1001 BRITTANY PKWY
MANCHESTER MO
63011-4325
US

V. Phone/Fax

Practice location:
  • Phone: 636-330-7246
  • Fax:
Mailing address:
  • Phone: 636-330-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN POLLOCK
Title or Position: MANAGER
Credential:
Phone: 636-330-7246