Provider Demographics
NPI:1982649125
Name:CHANLIONGCO, PETERPAUL MAYO (PT)
Entity Type:Individual
Prefix:
First Name:PETERPAUL
Middle Name:MAYO
Last Name:CHANLIONGCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 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:417-732-1388
Mailing Address - Fax:417-732-6014
Practice Address - Street 1:207 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:417-732-1388
Practice Address - Fax:417-732-6014
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100395225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000021900Medicare ID - Type Unspecified