Provider Demographics
NPI:1184900516
Name:PROFESSIONAL ATHLETIC REHABILITATION, LLC
Entity type:Organization
Organization Name:PROFESSIONAL ATHLETIC REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPORTS MEDICINE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:LAT
Authorized Official - Phone:314-598-1663
Mailing Address - Street 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:225 MARK TWAIN BUILDING
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4400
Mailing Address - Country:US
Mailing Address - Phone:314-598-1663
Mailing Address - Fax:314-516-5503
Practice Address - Street 1:1 UNIVERSITY BLVD
Practice Address - Street 2:225 MARK TWAIN BUILDING
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4400
Practice Address - Country:US
Practice Address - Phone:314-598-1663
Practice Address - Fax:314-516-5503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty