Healthcare Provider Details

I. General information

NPI: 1528339629
Provider Name (Legal Business Name): KEITH SANDERS PT MHS SCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CAMERA AVE
SAINT LOUIS MO
63126-1037
US

IV. Provider business mailing address

1000 CAMERA AVE
SAINT LOUIS MO
63126-1037
US

V. Phone/Fax

Practice location:
  • Phone: 314-691-2696
  • Fax:
Mailing address:
  • Phone: 314-691-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number110509
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: