1386961381 NPI number — MRS. KELLI JO YOUNGBLOOD PHYSICAL THERAPIST

Table of content: MRS. KELLI JO YOUNGBLOOD PHYSICAL THERAPIST (NPI 1386961381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386961381 NPI number — MRS. KELLI JO YOUNGBLOOD PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNGBLOOD
Provider First Name:
KELLI
Provider Middle Name:
JO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CASPER
Provider Other First Name:
KELLI
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386961381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
444 FOUR STATES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALENA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66739-4324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
444 FOUR STATES DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALENA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66739-4324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-783-4111
Provider Business Practice Location Address Fax Number:
620-783-4112
Provider Enumeration Date:
04/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2008020504 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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