Provider Demographics
NPI:1053449579
Name:LIFEVISION, INC.
Entity Type:Organization
Organization Name:LIFEVISION, INC.
Other - Org Name:PHYSICAL THERAPY INNOVATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:OPENLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:314-984-0068
Mailing Address - Street 1:338 S KIRKWOOD RD
Mailing Address - Street 2:UNIT 104B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6166
Mailing Address - Country:US
Mailing Address - Phone:314-984-0068
Mailing Address - Fax:314-984-0338
Practice Address - Street 1:338 S KIRKWOOD RD
Practice Address - Street 2:UNIT 104B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6166
Practice Address - Country:US
Practice Address - Phone:314-984-0068
Practice Address - Fax:314-984-0338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO115373OtherANTHEM BLUE CROSS BLUE SH
MO5769225OtherAETNA PROVIDER ID
MO64-01386OtherUNITED HEALTHCARE PROVIDE
MO000025131Medicare ID - Type Unspecified