Provider Demographics
NPI:1598277600
Name:KIRK, TAREN
Entity type:Individual
Prefix:
First Name:TAREN
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 N BUSINESS ROUTE 5 UNIT 1B
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-2659
Mailing Address - Country:US
Mailing Address - Phone:573-346-7445
Mailing Address - Fax:573-346-7673
Practice Address - Street 1:1930 N BUSINESS ROUTE 5 UNIT 1B
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2659
Practice Address - Country:US
Practice Address - Phone:573-346-7445
Practice Address - Fax:573-346-7673
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2010028338OtherSTATE OF MISSOURI DEVISION OF PROGRESSIONAL REGISTRATION PHYSICAL THERAPY