Provider Demographics
NPI:1538323324
Name:SYNERGY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SYNERGY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LAVACEK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:316-461-2321
Mailing Address - Street 1:3425 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-4919
Mailing Address - Country:US
Mailing Address - Phone:316-946-0990
Mailing Address - Fax:316-943-1139
Practice Address - Street 1:3425 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4919
Practice Address - Country:US
Practice Address - Phone:316-946-0990
Practice Address - Fax:316-943-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty