Healthcare Provider Details

I. General information

NPI: 1659577781
Provider Name (Legal Business Name): JOSEPH CHAD GUMM PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S 6TH ST
PACIFIC MO
63069-1328
US

IV. Provider business mailing address

261 CRESCENT AVE
VALLEY PARK MO
63088-1143
US

V. Phone/Fax

Practice location:
  • Phone: 636-257-4222
  • Fax:
Mailing address:
  • Phone: 314-560-7595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2002029173
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: