Healthcare Provider Details

I. General information

NPI: 1558652644
Provider Name (Legal Business Name): PRO-MOTION PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4642 SHENANDOAH AVE
SAINT LOUIS MO
63110-3424
US

IV. Provider business mailing address

3943 JUNIATA ST
SAINT LOUIS MO
63116-3911
US

V. Phone/Fax

Practice location:
  • Phone: 314-686-3008
  • Fax:
Mailing address:
  • Phone: 314-686-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2007028770
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MR. AZHAR SHAH
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: MSPT
Phone: 314-686-3008