=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295192003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MTS-ST. CHARLES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2016
-----------------------------------------------------
Last Update Date | 01/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4075 N SAINT PETERS PKWY
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63304-7396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-685-0402
-----------------------------------------------------
Fax | 636-685-0403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17300 NORTH OUTER 40 RD SUITE 202
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-1375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-728-1777
-----------------------------------------------------
Fax | 636-728-1793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL BORMAN
-----------------------------------------------------
Credential | PHD, PT, DMT, FAAOMP
-----------------------------------------------------
Telephone | 636-728-1777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------