Provider Demographics
NPI:1366454191
Name:BOLIVAR PHYSICAL THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:BOLIVAR PHYSICAL THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JANSEN
Authorized Official - Last Name:VANHOORNBEEK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:417-777-2888
Mailing Address - Street 1:1028 W BROADWAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1809
Mailing Address - Country:US
Mailing Address - Phone:417-777-2888
Mailing Address - Fax:417-777-4597
Practice Address - Street 1:1028 W BROADWAY ST STE A
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1809
Practice Address - Country:US
Practice Address - Phone:417-777-2888
Practice Address - Fax:417-777-4597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201276OtherBCBS OF MO GROUP ID
MO487223604Medicaid
MO505458208Medicaid
MO487223604Medicaid
MO000014677Medicare ID - Type UnspecifiedMEDICARE GROUP ID