Healthcare Provider Details

I. General information

NPI: 1255519930
Provider Name (Legal Business Name): ARIE V POREMBA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ARIK POREMBA

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 S NEW BALLAS RD SUITE 218E
SAINT LOUIS MO
63141-8705
US

IV. Provider business mailing address

777 S NEW BALLAS RD SUITE 218E
SAINT LOUIS MO
63141-8705
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-2562
  • Fax: 314-991-2593
Mailing address:
  • Phone: 314-991-2562
  • Fax: 314-991-2593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2007006528
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: