Basic Information
Provider Information | |||||||||
NPI: | 1174912984 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIKESCH | ||||||||
FirstName: | KAILA | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BEQUETTE | ||||||||
OtherFirstName: | KAILA | ||||||||
OtherMiddleName: | N | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 336 FESTUS CENTRE DR | ||||||||
Address2: |   | ||||||||
City: | FESTUS | ||||||||
State: | MO | ||||||||
PostalCode: | 630282458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362247511 | ||||||||
FaxNumber: | 6366382199 | ||||||||
Practice Location | |||||||||
Address1: | 3950 VOGEL RD | ||||||||
Address2: |   | ||||||||
City: | ARNOLD | ||||||||
State: | MO | ||||||||
PostalCode: | 630103790 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6364610900 | ||||||||
FaxNumber: | 6364610047 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2015 | ||||||||
LastUpdateDate: | 06/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2014027837 | MO | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.