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General NPI Number Information
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NPI Number | 1699836106
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Entity Type | Individual
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Provider Name | BLAINE G ELSENRAAT MPT
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Gender | Male
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1212 WEBER RD
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City | FARMINGTON
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State | MO
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Zip | 63640-3325
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Country | US
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Telephone | 573-701-7237
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Fax |
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Provider Business Mailing Address
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Address Line | 2517 LOMBARD LN
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City | IMPERIAL
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State | MO
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Zip | 63052-2055
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Country | US
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Telephone | 314-753-5116
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Fax |
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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 | 117857
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License Number State | MO
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