1164013116 NPI number — KOHOUT PHYSICAL THERAPY, LLC

Table of content: ALEXANDER BOGOMOLNIK (NPI 1063818540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164013116 NPI number — KOHOUT PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KOHOUT 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:
1164013116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 S COUNTRY CLUB DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68467-4009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-469-3634
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 E. 4TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-745-6399
Provider Business Practice Location Address Fax Number:
402-745-6388
Provider Enumeration Date:
02/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KOHOUT
Authorized Official First Name:
MARCUS
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
402-469-3634

Provider Taxonomy Codes

  • Taxonomy code: 2251S0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025822500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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