Provider Demographics
NPI:1164535217
Name:ST. CHARLES SPORTS&PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:ST. CHARLES SPORTS&PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-240-7000
Mailing Address - Street 1:939 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2910
Mailing Address - Country:US
Mailing Address - Phone:636-240-7000
Mailing Address - Fax:636-240-7513
Practice Address - Street 1:1840 ZUMBEHL RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-2761
Practice Address - Country:US
Practice Address - Phone:636-947-7678
Practice Address - Fax:636-947-4350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCH3930Medicare PIN
MO990001802Medicare PIN
MO0200620001Medicare NSC