Provider Demographics
NPI:1013031285
Name:STODDEN PHYSICAL THERAPY,LLC
Entity Type:Organization
Organization Name:STODDEN PHYSICAL THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:STODDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:402-289-5013
Mailing Address - Street 1:1405 N 205TH ST STODDEN PHYSICAL THERAPY,LLC
Mailing Address - Street 2:SU 140
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-4740
Mailing Address - Country:US
Mailing Address - Phone:402-289-5013
Mailing Address - Fax:402-289-5018
Practice Address - Street 1:11532 WILLOW PARK DR
Practice Address - Street 2:SU 100
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-6947
Practice Address - Country:US
Practice Address - Phone:402-289-5013
Practice Address - Fax:402-289-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1604174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025488800Medicaid
NE39960OtherBCBS
216813OtherCOVENTRY
NE10025488800Medicaid