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General NPI Number Information
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NPI Number | 1962012906
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Entity Type | Organization
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Legal Business Name | LIVING ACTIVE REHAB & WELLNESS
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Dates
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Enumeration Date | 08/04/2020
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Last Update Date | 09/15/2020
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Provider Practice Location Address
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Address Line | 1401 GETTYSBURG LNDG
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City | SAINT CHARLES
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State | MO
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Zip | 63303-6104
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Country | US
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Telephone | 636-443-9910
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 GETTYSBURG LNDG
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City | SAINT CHARLES
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State | MO
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Zip | 63303-6104
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Country | US
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Telephone | 636-443-9910
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Fax |
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Authorized Official
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Title or Position | OWNER, CEO
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Name | DR. KELLY BRAY
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Credential | PT, DPT
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Telephone | 636-443-9910
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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 |
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License Number State |
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