Provider Demographics
NPI:1013948975
Name:ADVANCED THERAPY & SPORTS MEDICINE, CHARTERED
Entity Type:Organization
Organization Name:ADVANCED THERAPY & SPORTS MEDICINE, CHARTERED
Other - Org Name:ADVANCED THERAPY & SPORTS MEDICINE,CHARTERED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
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:67530-3542
Mailing Address - Country:US
Mailing Address - Phone:620-792-7868
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261QP2000X261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200508610AMedicaid
KS200508610AMedicaid
KS5474700001Medicare NSC