=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255003158
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADAPTIVE EQUIPMENT CORNER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2021
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 252 PEORIA LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-3583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-206-8401
-----------------------------------------------------
Fax | 618-227-0097
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 252 PEORIA LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-3583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-206-8401
-----------------------------------------------------
Fax | 618-227-0097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SINGLE MEMBER
-----------------------------------------------------
Name | CYNTHIA HARDIN-WEISS
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 618-206-8401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------