Healthcare Provider Details

I. General information

NPI: 1871662767
Provider Name (Legal Business Name): PRINCETON PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 E HICKLAND ST
PRINCETON MO
64673-1227
US

IV. Provider business mailing address

807 E HICKLAND ST
PRINCETON MO
64673-1227
US

V. Phone/Fax

Practice location:
  • Phone: 660-748-3600
  • Fax: 660-748-3605
Mailing address:
  • Phone: 660-748-3600
  • Fax: 660-748-3605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number117457
License Number StateMO

VIII. Authorized Official

Name: AMY LEE MCDANIEL
Title or Position: OWNER-PHYSICAL THERAPY
Credential: MS, PT
Phone: 660-748-3600