Provider Demographics
NPI:1518378108
Name:HARRIS, TONY (LAT)
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-777-7763
Mailing Address - Fax:417-777-4378
Practice Address - Street 1:1600 UNIVERSITY AVE
Practice Address - Street 2:MEYER WELLNESS CENTER
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2578
Practice Address - Country:US
Practice Address - Phone:417-777-7763
Practice Address - Fax:417-777-4378
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070280202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer