Provider Demographics
NPI:1851425912
Name:CENTRAL PHYSICAL REHABILITATION AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:CENTRAL PHYSICAL REHABILITATION AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-429-4700
Mailing Address - Street 1:407 E RUSSELL AVE BLDG A
Mailing Address - Street 2:SUITE 6
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-1242
Mailing Address - Country:US
Mailing Address - Phone:660-429-4700
Mailing Address - Fax:660-429-0500
Practice Address - Street 1:407 E RUSSELL AVE BLDG A
Practice Address - Street 2:SUITE 6
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-1242
Practice Address - Country:US
Practice Address - Phone:660-429-4700
Practice Address - Fax:660-429-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ430000Medicare PIN