1497157267 NPI number — ADVANCED PT PCA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497157267 NPI number — ADVANCED PT PCA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PT PCA, 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:
Provider Other Organization Name Type Code:
6
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:
1497157267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2015
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:
67202-3013
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:
7111 E 21ST ST N
Provider Second Line Business Practice Location Address:
STE D-103
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67206-1090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-269-1311
Provider Business Practice Location Address Fax Number:
316-269-1588
Provider Enumeration Date:
09/23/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TODD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
316-263-0003

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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