Provider Demographics
NPI:1679036206
Name:ADVANCED THERAPY & SPORTS MED., LLC
Entity Type:Organization
Organization Name:ADVANCED THERAPY & SPORTS MED., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUPISET
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:620-792-7868
Mailing Address - Street 1:4801 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3252
Mailing Address - Country:US
Mailing Address - Phone:620-792-7868
Mailing Address - Fax:620-792-7867
Practice Address - Street 1:4801 10TH ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3252
Practice Address - Country:US
Practice Address - Phone:620-792-7868
Practice Address - Fax:620-792-7867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-10
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy