Basic Information
| Provider Information | |||||||||
| NPI: | 1134361868 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SIKESTON REHAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 S. KINGSHIGHWAY | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710110 | ||||||||
| FaxNumber: | 5734721880 | ||||||||
| Practice Location | |||||||||
| Address1: | 806 S. KINGSHIGHWAY | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710110 | ||||||||
| FaxNumber: | 5734721880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2009 | ||||||||
| LastUpdateDate: | 05/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | DAVIED | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | P.T./OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5734710110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 119750 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225X00000X | 004781 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 2012023604 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2008022311 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 000224 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 111613 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.