Provider Demographics
NPI:1790054534
Name:SUN LAKES PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SUN LAKES PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ARABELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-719-0699
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:204 SEMINARY STREET
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355-0383
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3379
Practice Address - Country:US
Practice Address - Phone:573-581-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011035212314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility