1518261320 NPI number — STARZ PEDIATRIC THERAPY NETWORK

Table of content: (NPI 1518261320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518261320 NPI number — STARZ PEDIATRIC THERAPY NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STARZ PEDIATRIC THERAPY NETWORK
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:
Provider Other Organization Name Type Code:
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:
1518261320
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1302 NW PERSIMMON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAIN VALLEY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64029-8628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-726-7337
Provider Business Mailing Address Fax Number:
816-847-0218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 NW JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAIN VALLEY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64029-8278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-726-7337
Provider Business Practice Location Address Fax Number:
816-847-0218
Provider Enumeration Date:
01/07/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NEWSOM
Authorized Official First Name:
STACEE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPIST, OWNER
Authorized Official Telephone Number:
816-726-7337

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1518261320 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".