Basic Information
| Provider Information | |||||||||
| NPI: | 1124216536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BST MORRIS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 WASHINGTON AVE | ||||||||
| Address2: | BST MORRIS LLC | ||||||||
| City: | ORTONVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562781357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208394271 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 ATLANTIC AVE | ||||||||
| Address2: | BST MORRIS LLC | ||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205855395 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 03/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | VANDOVER | ||||||||
| AuthorizedOfficialFirstName: | WADE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3208394152 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225200000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 842967700 | 05 | MN | MEDICAID |