Provider Demographics
NPI:1609965128
Name:PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY, LLC
Other - Org Name:REPUBLIC MEDICAL SUPPLY & REPUBLIC PHYSICAL THERAPY & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETERPAUL
Authorized Official - Middle Name:MAYO
Authorized Official - Last Name:CHANLIONGCO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:417-732-2344
Mailing Address - Street 1:213 US HIGHWAY 60 W
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1432
Mailing Address - Country:US
Mailing Address - Phone:417-732-2344
Mailing Address - Fax:417-732-6014
Practice Address - Street 1:213 US HIGHWAY 60 W
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1432
Practice Address - Country:US
Practice Address - Phone:417-732-2344
Practice Address - Fax:417-732-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100395261QP2000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202177OtherANTHEM BLUE CROSS BLUE SH
MO610616900OtherDEPARTMENT OF LABOR
MO610616900OtherDEPARTMENT OF LABOR
MO=========OtherTRICARE
MO=========REPOtherMERCY HEALTH PLANS
MO202177OtherANTHEM BLUE CROSS BLUE SH
MO=========REPOtherMERCY HEALTH PLANS
MODE6930Medicare ID - Type UnspecifiedMEDICARE RAILROAD PART B