Provider Demographics
NPI:1942417852
Name:FAMILY PHYSICAL THERAPY & SPORTS CENTER
Entity Type:Organization
Organization Name:FAMILY PHYSICAL THERAPY & SPORTS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARG
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-698-2820
Mailing Address - Street 1:211 W 33RD ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-3456
Mailing Address - Country:US
Mailing Address - Phone:308-236-5884
Mailing Address - Fax:308-236-9621
Practice Address - Street 1:321 GRAND AVE
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:NE
Practice Address - Zip Code:68869
Practice Address - Country:US
Practice Address - Phone:308-452-7154
Practice Address - Fax:308-452-7154
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY PHYSICAL THERAPY & SPORTS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-17
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE086994Medicare ID - Type UnspecifiedMEDICARE GROUP #