1518261320 NPI number — STARZ PEDIATRIC THERAPY NETWORK

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 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: 261QR0400X ; 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: 261QH0100X ; 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" .

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

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