Provider Demographics
NPI:1134443237
Name:TADURAN SPORTS MEDICINE AND OSTEOPATHIC WELLNESS CENTER
Entity type:Organization
Organization Name:TADURAN SPORTS MEDICINE AND OSTEOPATHIC WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TROY VIRGIL
Authorized Official - Middle Name:MAYPA
Authorized Official - Last Name:TADURAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:620-624-2565
Mailing Address - Street 1:102 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2784
Mailing Address - Country:US
Mailing Address - Phone:620-624-2565
Mailing Address - Fax:
Practice Address - Street 1:102 E 11TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2784
Practice Address - Country:US
Practice Address - Phone:620-624-2565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-34185261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS05-34185OtherLICENSE
FLOS 9896OtherLICENSE