Provider Demographics
NPI:1497539779
Name:MOXIE PELVIC HEALTH AND WELLNESS, PLLC
Entity Type:Organization
Organization Name:MOXIE PELVIC HEALTH AND WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:D
Authorized Official - Last Name:DA GAMA ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:217-320-3707
Mailing Address - Street 1:1830 BINNEY STATION RD
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-4425
Mailing Address - Country:US
Mailing Address - Phone:217-320-3707
Mailing Address - Fax:
Practice Address - Street 1:35 EXECUTIVE PLAZA CT
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5838
Practice Address - Country:US
Practice Address - Phone:618-226-8277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-21
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy