Healthcare Provider Details

I. General information

NPI: 1134167331
Provider Name (Legal Business Name): THEODORE BROOKE NELSON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5764 S FARM ROAD 203
ROGERSVILLE MO
65742-6436
US

IV. Provider business mailing address

PO BOX 11031
SPRINGFIELD MO
65808-1031
US

V. Phone/Fax

Practice location:
  • Phone: 417-844-0223
  • Fax: 417-864-5781
Mailing address:
  • Phone: 417-844-0223
  • Fax: 417-864-5781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number107405
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: