=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295697878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANSFORMING PHYSICAL THERAPY LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2025
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 S 1ST ST
-----------------------------------------------------
City | VANDALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62471-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-283-1634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 S 1ST ST
-----------------------------------------------------
City | VANDALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62471-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTIE ROSE CARTER
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 618-335-4271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------