Healthcare Provider Details

I. General information

NPI: 1235511460
Provider Name (Legal Business Name): LANI BUERCK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11960 WESTLINE INDUSTRIAL DRIVE SUITE 201
ST. LOUIS MO
63146
US

IV. Provider business mailing address

1029 LOTTES BLVD
PERRYVILLE MO
63775
US

V. Phone/Fax

Practice location:
  • Phone: 866-433-9555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2014002067
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: