Healthcare Provider Details

I. General information

NPI: 1669004735
Provider Name (Legal Business Name): ROBERT THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 REGENT DR
WARRENSBURG MO
64093-3231
US

IV. Provider business mailing address

1600 KIMBERLY CT
GREENWOOD MO
64034-8700
US

V. Phone/Fax

Practice location:
  • Phone: 660-429-4444
  • Fax:
Mailing address:
  • Phone: 660-221-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2011025967
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: