Healthcare Provider Details

I. General information

NPI: 1700172400
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11960 WESTLINE INDUSTRIAL DR STE 201
SAINT LOUIS MO
63146-3209
US

IV. Provider business mailing address

11960 WESTLINE INDUSTRIAL DR STE 201
SAINT LOUIS MO
63146-3209
US

V. Phone/Fax

Practice location:
  • Phone: 314-819-0480
  • Fax:
Mailing address:
  • Phone: 314-819-0480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2008015492
License Number StateMO

VIII. Authorized Official

Name: KATRINA RENEE PRUTCH
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential: PTA
Phone: 719-214-0922