Healthcare Provider Details

I. General information

NPI: 1710385109
Provider Name (Legal Business Name): TYLER BAUMHOER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W CLAY RD
VERSAILLES MO
60584
US

IV. Provider business mailing address

1101 W CLAY RD
VERSAILLES MO
65084-1177
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-5411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2013025652
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: