Provider Demographics
NPI:1841477288
Name:STORCK, DUSTIN (DPT)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:STORCK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 36
Mailing Address - Street 2:
Mailing Address - City:FARINA
Mailing Address - State:IL
Mailing Address - Zip Code:62838-9421
Mailing Address - Country:US
Mailing Address - Phone:618-795-0667
Mailing Address - Fax:
Practice Address - Street 1:1190 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7358
Practice Address - Country:US
Practice Address - Phone:314-286-6988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70015924225100000X
MO2007034391225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy