1700175619 NPI number — WESTERN TRAILS PHYSICAL THERAPY, LLC

Table of content: (NPI 1700175619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700175619 NPI number — WESTERN TRAILS PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN TRAILS 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:
1700175619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1463 19TH AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MITCHELL
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69357-1455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-623-1313
Provider Business Mailing Address Fax Number:
308-623-1315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1463 19TH AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MITCHELL
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69357-1455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-623-1313
Provider Business Practice Location Address Fax Number:
308-623-1315
Provider Enumeration Date:
03/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BOWLIN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
WESLY
Authorized Official Title or Position:
OWNER/MANAGER/PRESIDENT
Authorized Official Telephone Number:
308-623-1313

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2684 , 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)





Copyright © 2007-2025 www.npivalidator.com