Organization
EXCEL PHYSICAL THERAPY & SPORTS MEDICINE CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JILL S MCCORMICK P.T., A.T.C. (OWNER)
(773) 892-7501
Entity
Organization
Contact information
Practice address
1420 W ASHLEY RD, BOONVILLE, MO 65233-2112
(660) 882-6115
(660) 882-6120
Mailing address
1420 W ASHLEY RD, BOONVILLE, MO 65233-2112
(660) 882-6115
(660) 882-6120
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
108639
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
122566
BLUE CROSS BLUE SHEILD
—
01
—
DA1611
MEDICARE RAILROAD
MO
Enumeration date
12/21/2006
Last updated
10/16/2007
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