Provider Demographics
NPI:1326551532
Name:FAMILY PHYSICAL THERAPY & SPORTS CENTER
Entity Type:Organization
Organization Name:FAMILY PHYSICAL THERAPY & SPORTS CENTER
Other - Org Name:FAMILY PHYSICAL THERAPY AND CHIROPRACTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:FIDDELKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-452-7154
Mailing Address - Street 1:211 W 33RD ST STE A
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-3485
Mailing Address - Country:US
Mailing Address - Phone:308-452-7154
Mailing Address - Fax:308-452-3394
Practice Address - Street 1:620 E 25TH ST STE 7
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5529
Practice Address - Country:US
Practice Address - Phone:308-455-1781
Practice Address - Fax:308-455-1782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1928111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty