1356617757 NPI number — COLLEGE PARK ANCILLARY, LLC

Table of content: (NPI 1356617757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356617757 NPI number — COLLEGE PARK ANCILLARY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLLEGE PARK ANCILLARY, 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:
COLLEGE PARK PHYSICAL THERAPY
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:
1356617757
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742554
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-2105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-469-0503
Provider Business Mailing Address Fax Number:
913-469-5267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10600 MASTIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66212-5723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-681-0606
Provider Business Practice Location Address Fax Number:
913-338-1311
Provider Enumeration Date:
03/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMBERS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
O
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
913-469-0503

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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