Basic Information
| Provider Information | |||||||||
| NPI: | 1477190395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLD | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | VICTORIA | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5564 MEADOWVIEW CT SE | ||||||||
| Address2: | |||||||||
| City: | PRIOR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553723374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125780120 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2725 N WESTWOOD BLVD STE 17 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639012367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737789348 | ||||||||
| FaxNumber: | 5736864870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2019 | ||||||||
| LastUpdateDate: | 12/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/10/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2019035821 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.