Provider Demographics
NPI:1023337391
Name:PHYSICAL THERAPY CLINIC OF AVA, P.C.
Entity type:Organization
Organization Name:PHYSICAL THERAPY CLINIC OF AVA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY / 50 OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYLENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAGUIO
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:417-683-3380
Mailing Address - Street 1:1307 HADEN STREET
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608-5105
Mailing Address - Country:US
Mailing Address - Phone:417-683-3380
Mailing Address - Fax:417-683-3386
Practice Address - Street 1:1307 HADEN STREET
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608-5105
Practice Address - Country:US
Practice Address - Phone:417-683-3380
Practice Address - Fax:417-683-3386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0891261QP2000X
MOR0933261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO756697306Medicaid
MO756697306Medicaid