Basic Information
| Provider Information | |||||||||
| NPI: | 1457010647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVERENZ | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 424 N FULLENWIDER ST | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652401022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738819022 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1238 REMINGTON DR. | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736822230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2021 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2021021352 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.