Provider Demographics
NPI:1558796144
Name:KPO REHABILITATION & SPORTS MEDICINE
Entity Type:Organization
Organization Name:KPO REHABILITATION & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:907-262-2596
Mailing Address - Street 1:221 W MARYDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7420
Mailing Address - Country:US
Mailing Address - Phone:907-262-2596
Mailing Address - Fax:907-262-2765
Practice Address - Street 1:130 S WILLOW ST
Practice Address - Street 2:SUITE 1
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7744
Practice Address - Country:US
Practice Address - Phone:907-262-2596
Practice Address - Fax:907-262-2765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPT0695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty