Provider Demographics
NPI:1770514879
Name:SPORTS AND PHYSICAL THERAPY CENTER
Entity type:Organization
Organization Name:SPORTS AND PHYSICAL THERAPY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:636-938-4065
Mailing Address - Street 1:322 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1826
Mailing Address - Country:US
Mailing Address - Phone:636-938-4065
Mailing Address - Fax:636-938-4067
Practice Address - Street 1:322 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-1826
Practice Address - Country:US
Practice Address - Phone:636-938-4065
Practice Address - Fax:636-938-4067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001005492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11299OtherESSENCE
P00158791OtherMEDICARE RAILROAD
683038OtherHEALTHLINK
227075OtherGHP ADVANTRA CMR
6400737OtherUNITED HEALTHCARE
MO193453OtherBLUE CROSS BLUE SHIELD
610149300OtherDEPARTMENT OF LABOR
7889614OtherAETNA
227075OtherGHP ADVANTRA CMR
683038OtherHEALTHLINK
=========001OtherTRICARE