Healthcare Provider Details

I. General information

NPI: 1629492111
Provider Name (Legal Business Name): MTS-LAKE SAINT LOUIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 WINGHAVEN BLVD
O FALLON MO
63368-3623
US

IV. Provider business mailing address

9961 WINGHAVEN BLVD
O FALLON MO
63368-3623
US

V. Phone/Fax

Practice location:
  • Phone: 636-728-1777
  • Fax:
Mailing address:
  • Phone: 636-728-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAN WASHECK
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT
Phone: 636-699-9357