Healthcare Provider Details

I. General information

NPI: 1598036907
Provider Name (Legal Business Name): PROGRESSIVE PHYSICAL AND SPORTS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 WOLFRUM RD
WELDON SPRING MO
63304-7625
US

IV. Provider business mailing address

1043 WOLFRUM RD
WELDON SPRING MO
63304-7625
US

V. Phone/Fax

Practice location:
  • Phone: 636-300-4600
  • Fax: 636-300-4603
Mailing address:
  • Phone: 636-300-4600
  • Fax: 636-300-4603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number01952
License Number StateMO

VIII. Authorized Official

Name: MS. PATRICIA LEE TRACY
Title or Position: OWNER
Credential: P.T.
Phone: 636-300-4600