Provider Demographics
NPI:1689380362
Name:DICKSON DIVELEY MIDWEST ORTHOPAEDIC CLINIC LLC
Entity Type:Organization
Organization Name:DICKSON DIVELEY MIDWEST ORTHOPAEDIC CLINIC LLC
Other - Org Name:KANSAS CITY ORTHOPEDIC ALLIANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIVELBISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-319-7600
Mailing Address - Street 1:3651 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1910
Mailing Address - Country:US
Mailing Address - Phone:913-319-7600
Mailing Address - Fax:913-253-1702
Practice Address - Street 1:201 NW R D MIZE RD STE 250
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2513
Practice Address - Country:US
Practice Address - Phone:913-319-7600
Practice Address - Fax:913-253-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies