Provider Demographics
NPI:1457457418
Name:INOCENCIO, MIKE (PT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:INOCENCIO
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 1:1100 E OUTER RD S STE 1
Mailing Address - Street 2:PO BOX 244
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-1701
Mailing Address - Country:US
Mailing Address - Phone:573-288-3311
Mailing Address - Fax:573-288-1223
Practice Address - Street 1:1100 E OUTER RD S STE 1
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MO
Practice Address - Zip Code:63435-1701
Practice Address - Country:US
Practice Address - Phone:573-288-3311
Practice Address - Fax:573-288-1223
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist