Provider Demographics
NPI:1144394164
Name:OMAHA SPORTS PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:OMAHA SPORTS PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:POTACH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:402-330-2774
Mailing Address - Street 1:12100 W CENTER RD
Mailing Address - Street 2:SUITE 525
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3969
Mailing Address - Country:US
Mailing Address - Phone:402-330-2774
Mailing Address - Fax:402-330-2779
Practice Address - Street 1:12100 W CENTER RD
Practice Address - Street 2:SUITE 525
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3969
Practice Address - Country:US
Practice Address - Phone:402-330-2774
Practice Address - Fax:402-330-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10024986200Medicaid
NE10024986200Medicaid