Provider Demographics
NPI:1891985776
Name:ADVANCE PHYCIAL THERAPY & SPORTS MED
Entity type:Organization
Organization Name:ADVANCE PHYCIAL THERAPY & SPORTS MED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:P.T./OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FLESHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:660-665-5333
Mailing Address - Street 1:1108 E PATTERSON ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4002
Mailing Address - Country:US
Mailing Address - Phone:660-665-5333
Mailing Address - Fax:660-665-5332
Practice Address - Street 1:1108 E PATTERSON ST
Practice Address - Street 2:SUITE 6
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4002
Practice Address - Country:US
Practice Address - Phone:660-665-5333
Practice Address - Fax:660-665-5332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO02255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO170596OtherBCBS
MO990001800OtherMEDICARE
MO432216OtherHEALTHLINK
MO487853517Medicaid