1013031285 NPI number — STODDEN PHYSICAL THERAPY,LLC

Table of content: (NPI 1013031285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013031285 NPI number — STODDEN PHYSICAL THERAPY,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STODDEN PHYSICAL THERAPY,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:
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:
1013031285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 N 205TH ST STODDEN PHYSICAL THERAPY,LLC
Provider Second Line Business Mailing Address:
SU 140
Provider Business Mailing Address City Name:
ELKHORN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68022-4740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-289-5013
Provider Business Mailing Address Fax Number:
402-289-5018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11532 WILLOW PARK DR
Provider Second Line Business Practice Location Address:
SU 100
Provider Business Practice Location Address City Name:
GRETNA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68028-6947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-289-5013
Provider Business Practice Location Address Fax Number:
402-289-5018
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STODDEN
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-289-5013

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  1604 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025488800 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39960 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 216813 . This is a "COVENTRY" identifier . This identifiers is of the category "OTHER".




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