Basic Information
| Provider Information | |||||||||
| NPI: | 1457396756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL THERAPY OF HIGGINSVILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 FAIRGROUND AVE | ||||||||
| Address2: | |||||||||
| City: | HIGGINSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640371638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605847801 | ||||||||
| FaxNumber: | 6605848619 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 FAIRGROUND AVE | ||||||||
| Address2: | |||||||||
| City: | HIGGINSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640371638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605847801 | ||||||||
| FaxNumber: | 6605848619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | BRUMMEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 6605847801 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MED RPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 29748028 | 01 | MO | BCBSKC | OTHER |