1073579819 NPI number — ELKHORN PHYSICAL THERAPY PC

Table of content: EDWARD MOORE M.A. (NPI 1407176803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073579819 NPI number — ELKHORN PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELKHORN PHYSICAL THERAPY PC
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:
1073579819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20289 WIRT STREET
Provider Second Line Business Mailing Address:
PO BOX 177
Provider Business Mailing Address City Name:
ELKHORN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68022-1417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-289-3288
Provider Business Mailing Address Fax Number:
402-289-2550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20289 WIRT ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHORN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68022-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-289-3288
Provider Business Practice Location Address Fax Number:
402-289-2550
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLEEMAN
Authorized Official First Name:
ROLAND
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
402-289-3288

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: 02067 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 39576 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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