Healthcare Provider Details

I. General information

NPI: 1295123420
Provider Name (Legal Business Name): ERIN EGGEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 CLAY STREET
VERSAILLES MO
65084
US

IV. Provider business mailing address

445 KAYLOR BRIDGE RD
CENTERTOWN MO
65023-3623
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-5411
  • Fax:
Mailing address:
  • Phone: 573-619-4804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: