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General NPI Number Information
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NPI Number | 1962878488
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Entity Type | Organization
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Legal Business Name | THERA-PEDS, LLC
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Dates
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Enumeration Date | 08/19/2015
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Last Update Date | 12/29/2015
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Provider Practice Location Address
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Address Line | 115 PROGRESS PKWY
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City | SULLIVAN
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State | MO
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Zip | 63080-2359
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Country | US
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Telephone | 573-468-3373
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Fax |
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Provider Business Mailing Address
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Address Line | 10276 TIMMERMANN LN
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City | SULLIVAN
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State | MO
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Zip | 63080-6436
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | LAURA PEREGOY
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Credential | OTR/L
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Telephone | 573-259-1425
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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