Provider Demographics
NPI:1740400779
Name:PHYSICAL AND SPORTS THERAPY SERVICES OF ST LOUIS
Entity Type:Organization
Organization Name:PHYSICAL AND SPORTS THERAPY SERVICES OF ST LOUIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT DIP MDT
Authorized Official - Phone:314-726-1186
Mailing Address - Street 1:950 FRANCIS PL
Mailing Address - Street 2:SUITE 15
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2465
Mailing Address - Country:US
Mailing Address - Phone:314-726-1186
Mailing Address - Fax:314-726-0176
Practice Address - Street 1:950 FRANCIS PL
Practice Address - Street 2:SUITE 15
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-2465
Practice Address - Country:US
Practice Address - Phone:314-726-1186
Practice Address - Fax:314-726-0176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0063261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy