Healthcare Provider Details

I. General information

NPI: 1407044548
Provider Name (Legal Business Name): MISSOURI CENTRAL PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2759 A SOUTH CLARK
MEXICO MO
65265
US

IV. Provider business mailing address

2759 A SOUTH CLARK
MEXICO MO
65265
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-1880
  • Fax: 573-581-6678
Mailing address:
  • Phone: 573-581-1880
  • Fax: 573-581-6678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: KANE FREEMAN
Title or Position: CO-OWNER/ PT
Credential:
Phone: 573-581-1880