Healthcare Provider Details

I. General information

NPI: 1952362352
Provider Name (Legal Business Name): ACTIVE CARE PHYSICAL THERAPY & SPINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5497A HIGHWAY 54
OSAGE BEACH MO
65065-3026
US

IV. Provider business mailing address

5497A HIGHWAY 54
OSAGE BEACH MO
65065-3026
US

V. Phone/Fax

Practice location:
  • Phone: 573-302-1288
  • Fax: 573-302-1384
Mailing address:
  • Phone: 573-302-1288
  • Fax: 573-302-1384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number102576
License Number StateMO

VIII. Authorized Official

Name: MR. MICHAEL L MCCLAUGHRY
Title or Position: PARTNER
Credential: P T
Phone: 573-302-1288