Healthcare Provider Details

I. General information

NPI: 1902178106
Provider Name (Legal Business Name): ROBERT EUGENE MCDOUGLE LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22865 COUNTYLINE RD
SHELL KNOB MO
65747-7503
US

IV. Provider business mailing address

22865 COUNTYLINE RD
SHELL KNOB MO
65747-7503
US

V. Phone/Fax

Practice location:
  • Phone: 417-858-2421
  • Fax:
Mailing address:
  • Phone: 417-858-2421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number116059
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: