Healthcare Provider Details

I. General information

NPI: 1336122266
Provider Name (Legal Business Name): BRENTWOOD PHYSICAL THERAPY LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 02/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2558 S BRENTWOOD BLVD
SAINT LOUIS MO
63144-2309
US

IV. Provider business mailing address

2558 S BRENTWOOD BLVD
SAINT LOUIS MO
63144-2309
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-8940
  • Fax: 314-961-8969
Mailing address:
  • Phone: 314-961-8940
  • Fax: 314-961-8969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT SHAWN TUCKER
Title or Position: PRESIDENT
Credential: PT
Phone: 314-961-8940