Provider Demographics
NPI:1558348789
Name:PLACE, NATHAN ALAN (AT,C)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:ALAN
Last Name:PLACE
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 QUIVER DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3721
Mailing Address - Country:US
Mailing Address - Phone:636-272-1396
Mailing Address - Fax:
Practice Address - Street 1:3451 PHEASANT MEADOW DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7324
Practice Address - Country:US
Practice Address - Phone:636-379-0092
Practice Address - Fax:636-978-8299
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113476225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner