Basic Information
| Provider Information | |||||||||
| NPI: | 1396854915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | MONROE | ||||||||
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| Credential: | MHO PT SCS ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 730 JOACHIM ST | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630281414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362088163 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1355 MAPLE STREET | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737569900 | ||||||||
| FaxNumber: | 5737569988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 02273 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.