=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427272434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EUREKA PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 429 MERAMEC BLVD.
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63025-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-938-9373
-----------------------------------------------------
Fax | 636-938-9373
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 429 MERAMEC BLVD
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63025-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-938-9373
-----------------------------------------------------
Fax | 636-938-9373
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. KIM MARIE MILLER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 636-938-9373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | R0728
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------