Provider Demographics
NPI:1821877143
Name:BADOLIAN, JOHN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:BADOLIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6304 COUNTY ROAD 1820
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:MO
Mailing Address - Zip Code:65789-9171
Mailing Address - Country:US
Mailing Address - Phone:417-362-0092
Mailing Address - Fax:
Practice Address - Street 1:215 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-1442
Practice Address - Country:US
Practice Address - Phone:417-362-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019011455225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist