Provider Demographics
NPI:1336122266
Name:BRENTWOOD PHYSICAL THERAPY LIMITED
Entity Type:Organization
Organization Name:BRENTWOOD PHYSICAL THERAPY LIMITED
Other - Org Name:BRENTWOOD CENTER OF HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:314-961-8940
Mailing Address - Street 1:2558 S BRENTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2309
Mailing Address - Country:US
Mailing Address - Phone:314-961-8940
Mailing Address - Fax:314-961-8969
Practice Address - Street 1:2558 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2309
Practice Address - Country:US
Practice Address - Phone:314-961-8940
Practice Address - Fax:314-961-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2013-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO31348OtherBCBS
MO266569Medicare Oscar/Certification