Provider Demographics
NPI:1134361868
Name:SIKESTON REHAB, LLC
Entity type:Organization
Organization Name:SIKESTON REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.T./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIED
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:573-471-0110
Mailing Address - Street 1:806 S. KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801
Mailing Address - Country:US
Mailing Address - Phone:573-471-0110
Mailing Address - Fax:573-472-1880
Practice Address - Street 1:806 S. KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801
Practice Address - Country:US
Practice Address - Phone:573-471-0110
Practice Address - Fax:573-472-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119750225200000X
MO004781225X00000X
MO2012023604225100000X
MO2008022311225100000X
MO000224225100000X
MO111613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6688480001Medicare NSC