1174699045 NPI number — ELITE SPORTS MEDICINE & PHYSICAL THERAPY LC

Table of content: DR. JESSICA JISEON CHO M.D. (NPI 1023162039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174699045 NPI number — ELITE SPORTS MEDICINE & PHYSICAL THERAPY LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE SPORTS MEDICINE & PHYSICAL THERAPY LC
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:
1174699045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12728 STATE LINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEAWOOD
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66209-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-888-0014
Provider Business Mailing Address Fax Number:
816-941-2520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12728 STATE LINE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAWOOD
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66209-1919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-888-0014
Provider Business Practice Location Address Fax Number:
816-941-2520
Provider Enumeration Date:
11/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAZZA
Authorized Official First Name:
BIAGIO
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
913-888-0014

Provider Taxonomy Codes

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

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





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