Provider Demographics
NPI:1336104413
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 & OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:J
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
Mailing Address - Street 2:SUITE 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 1:1405 N 205TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-4740
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:2006-04-20
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
39960OtherBCBS
216813OtherCOVENTRY
NE10025112300Medicaid
NE278993Medicare PIN
216813OtherCOVENTRY
39960OtherBCBS