Healthcare Provider Details

I. General information

NPI: 1548694292
Provider Name (Legal Business Name): ROB EDWARD LIGHT MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 LINE AVE
ROLLA MO
65401-9620
US

IV. Provider business mailing address

1712 LINE AVE
ROLLA MO
65401-9620
US

V. Phone/Fax

Practice location:
  • Phone: 573-578-6121
  • Fax:
Mailing address:
  • Phone: 573-578-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number116304
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: