Healthcare Provider Details

I. General information

NPI: 1467315689
Provider Name (Legal Business Name): SCOTT BRUECKNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 E ELM ST
REPUBLIC MO
65738-1552
US

IV. Provider business mailing address

776 LADY OF THE WOODS LN
NIXA MO
65714-4253
US

V. Phone/Fax

Practice location:
  • Phone: 573-579-2889
  • Fax:
Mailing address:
  • Phone: 573-579-2889
  • Fax: 573-579-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: