1235564899 NPI number — EXCEL SPINE SPORT AND PERFORMANCE LLC

Table of content: (NPI 1235564899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235564899 NPI number — EXCEL SPINE SPORT AND PERFORMANCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCEL SPINE SPORT AND PERFORMANCE 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:
1235564899
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8550 MARSHALL DR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
LENEXA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-888-4845
Provider Business Mailing Address Fax Number:
913-888-9248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8550 MARSHALL DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LENEXA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-888-4845
Provider Business Practice Location Address Fax Number:
913-888-9248
Provider Enumeration Date:
09/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LIGON
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
ADAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
913-888-4845

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  01-05574 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com