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General NPI Number Information
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NPI Number | 1134167331
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Entity Type | Individual
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Provider Name | THEODORE BROOKE NELSON P.T.
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Gender | Male
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Dates
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Enumeration Date | 06/02/2006
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Last Update Date | 08/20/2009
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Provider Practice Location Address
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Address Line | 5764 S FARM ROAD 203
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City | ROGERSVILLE
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State | MO
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Zip | 65742-6436
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Country | US
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Telephone | 417-844-0223
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Fax | 417-864-5781
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Provider Business Mailing Address
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Address Line | PO BOX 11031
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City | SPRINGFIELD
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State | MO
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Zip | 65808-1031
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Country | US
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Telephone | 417-844-0223
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Fax | 417-864-5781
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 107405
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License Number State | MO
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