1104991702 NPI number — ADVANCED PT LLC

Table of content: (NPI 1104991702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104991702 NPI number — ADVANCED PT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PT LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PREFERRED PT CHERRY LANE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104991702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W DOUGLAS AVE
Provider Second Line Business Mailing Address:
STE 1040
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67202-3017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-263-0003
Provider Business Mailing Address Fax Number:
316-263-1241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 W CHERRY LN
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-855-2099
Provider Business Practice Location Address Fax Number:
208-855-2155
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TODD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
316-260-6869

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DG5887 . This is a "RETIRED RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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