Provider Demographics
NPI:1255362513
Name:ADVANCED PT COFFEYVILLE LLC
Entity type:Organization
Organization Name:ADVANCED PT COFFEYVILLE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:P.T./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:316-260-6869
Mailing Address - Street 1:200 W DOUGLAS
Mailing Address - Street 2:STE 1040
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3017
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:2205 W 8TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-2936
Practice Address - Country:US
Practice Address - Phone:620-251-5839
Practice Address - Fax:620-251-5839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-00261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSDD2834OtherRAILROAD MEDICARE
KS115660Medicare PIN