1649507914 NPI number — ADVANCED PT, LLC

Table of content: (NPI 1649507914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649507914 NPI number — ADVANCED PT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PT, 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:
1649507914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W DOUGLAS AVE
Provider Second Line Business Mailing Address:
STE. 1040
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67202-3013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-263-0003
Provider Business Mailing Address Fax Number:
316-263-1241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 W IOWA AVE
Provider Second Line Business Practice Location Address:
STE. B
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-2826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-466-2200
Provider Business Practice Location Address Fax Number:
208-466-2300
Provider Enumeration Date:
11/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TODD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
316-260-6869

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT-2364 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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