Provider Demographics
NPI:1043684202
Name:CVPT-ST. CHARLES, LLC
Entity Type:Organization
Organization Name:CVPT-ST. CHARLES, LLC
Other - Org Name:ST. LOUIS PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PT, DMT, FAAOMP
Authorized Official - Phone:636-728-1777
Mailing Address - Street 1:17300 NORTH OUTER 40 RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1375
Mailing Address - Country:US
Mailing Address - Phone:636-728-1777
Mailing Address - Fax:
Practice Address - Street 1:4075 N SAINT PETERS PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-7396
Practice Address - Country:US
Practice Address - Phone:636-728-1777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-25
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010025564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty