1659742047 NPI number — C.O.R.E. PHYSICAL THERAPY AND SPORTS PERFORMANCE PC

Table of content: (NPI 1659742047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659742047 NPI number — C.O.R.E. PHYSICAL THERAPY AND SPORTS PERFORMANCE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
C.O.R.E. PHYSICAL THERAPY AND SPORTS PERFORMANCE PC
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:
1659742047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17660 WRIGHT ST STE 9AND10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68130-2102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-933-4027
Provider Business Mailing Address Fax Number:
402-933-5027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17660 WRIGHT ST # ST910
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68130-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-933-4027
Provider Business Practice Location Address Fax Number:
402-933-5027
Provider Enumeration Date:
10/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RATHJEN
Authorized Official First Name:
CLAIRE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DOCTOR OF PHYSICAL THERAPY
Authorized Official Telephone Number:
402-933-4027

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  2675 , 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)





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