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General NPI Number Information
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NPI Number | 1700138377
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Entity Type | Organization
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Legal Business Name | ADVANCED SPORTS AND REHAB, LLC
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Dates
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Enumeration Date | 10/08/2012
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Last Update Date | 02/27/2013
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Provider Practice Location Address
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Address Line | 1011 S MADISON ST
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City | MALDEN
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State | MO
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Zip | 63863-2462
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Country | US
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Telephone | 573-276-4999
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Fax | 573-276-5084
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Provider Business Mailing Address
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Address Line | 1899 N WESTWOOD BLVD SUITE C, PMB 113
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-2833
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Country | US
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Telephone | 573-785-3966
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Fax | 573-785-3966
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. JAMES DENNIS KEELING
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Credential | M.A., CCC-SLP
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Telephone | 573-718-2699
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State |
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