Provider Demographics
NPI:1700172400
Name:SUPPLEMENTAL HEALTH CARE
Entity type:Organization
Organization Name:SUPPLEMENTAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:PRUTCH
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:719-214-0922
Mailing Address - Street 1:11960 WESTLINE INDUSTRIAL DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3209
Mailing Address - Country:US
Mailing Address - Phone:314-819-0480
Mailing Address - Fax:
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR STE 201
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:314-819-0480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008015492261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy