Healthcare Provider Details

I. General information

NPI: 1164414918
Provider Name (Legal Business Name): ADVANCED PHYSICAL THERAPY & FITNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 PLAZA DR STE G
SAINT CLAIR MO
63077-1146
US

IV. Provider business mailing address

960 PLAZA DR STE G
SAINT CLAIR MO
63077-1146
US

V. Phone/Fax

Practice location:
  • Phone: 636-629-7778
  • Fax: 636-629-7778
Mailing address:
  • Phone: 636-629-7778
  • Fax: 636-629-7778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01720
License Number StateMO

VIII. Authorized Official

Name: MRS. LAURIE A AUBUCHON
Title or Position: OWNER
Credential: R.P.T.
Phone: 636-629-7778