Healthcare Provider Details

I. General information

NPI: 1861584658
Provider Name (Legal Business Name): CYNTHIA THERESE BADOLIAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 PORTER WAGONER BLVD STE 1
WEST PLAINS MO
65775-1806
US

IV. Provider business mailing address

6304 COUNTY ROAD 1820
POMONA MO
65789-9171
US

V. Phone/Fax

Practice location:
  • Phone: 417-204-9696
  • Fax:
Mailing address:
  • Phone: 417-204-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2019029196
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2006029256
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: