Provider Demographics
NPI:1952804668
Name:EQUI-LIBRIUM THERAPY CENTER
Entity Type:Organization
Organization Name:EQUI-LIBRIUM THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:PUTTHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-830-1409
Mailing Address - Street 1:1148 S COURTNEY LN
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-4501
Mailing Address - Country:US
Mailing Address - Phone:417-830-1409
Mailing Address - Fax:
Practice Address - Street 1:1148 S COURTNEY LN
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-4501
Practice Address - Country:US
Practice Address - Phone:417-830-1409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy