Basic Information
Provider Information | |||||||||
NPI: | 1780075754 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANTAGE HAND THERAPY & ORTHOPEDIC REHABILITATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVANTAGE THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9163 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658019163 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178894800 | ||||||||
FaxNumber: | 4178890980 | ||||||||
Practice Location | |||||||||
Address1: | 864 E HWY 60 | ||||||||
Address2: |   | ||||||||
City: | MONETT | ||||||||
State: | MO | ||||||||
PostalCode: | 657089376 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4176351185 | ||||||||
FaxNumber: | 4176351187 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2015 | ||||||||
LastUpdateDate: | 02/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCROGGINS | ||||||||
AuthorizedOfficialFirstName: | JEANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4178894800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2014023789 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.