Provider Demographics
NPI:1700138377
Name:ADVANCED SPORTS AND REHAB, LLC
Entity type:Organization
Organization Name:ADVANCED SPORTS AND REHAB, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:KEELING
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:573-718-2699
Mailing Address - Street 1:1899 N WESTWOOD BLVD
Mailing Address - Street 2:SUITE C, PMB 113
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2833
Mailing Address - Country:US
Mailing Address - Phone:573-785-3966
Mailing Address - Fax:573-785-3966
Practice Address - Street 1:1011 S MADISON ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-2462
Practice Address - Country:US
Practice Address - Phone:573-276-4999
Practice Address - Fax:573-276-5084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266628Medicare Oscar/Certification