Provider Demographics
NPI: | 1104379353 |
---|---|
Name: | POTENTIAL THERAPY SERVICES LLC |
Entity Type: | Organization |
Organization Name: | POTENTIAL THERAPY SERVICES LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | TYLER |
Authorized Official - Middle Name: | R |
Authorized Official - Last Name: | BROWN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PT |
Authorized Official - Phone: | 573-608-5058 |
Mailing Address - Street 1: | 60 PLAZA DR |
Mailing Address - Street 2: | |
Mailing Address - City: | STE GENEVIEVE |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63670-1800 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 573-608-5058 |
Mailing Address - Fax: | 844-912-8618 |
Practice Address - Street 1: | 60 PLAZA DR |
Practice Address - Street 2: | |
Practice Address - City: | STE GENEVIEVE |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63670-1800 |
Practice Address - Country: | US |
Practice Address - Phone: | 573-608-5058 |
Practice Address - Fax: | 844-912-8618 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-07-24 |
Last Update Date: | 2022-08-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2001001890 | 261QP2000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |