Provider Demographics
NPI:1356617757
Name:COLLEGE PARK ANCILLARY, LLC
Entity type:Organization
Organization Name:COLLEGE PARK ANCILLARY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:O
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-469-0503
Mailing Address - Street 1:PO BOX 742554
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2105
Mailing Address - Country:US
Mailing Address - Phone:913-469-0503
Mailing Address - Fax:913-469-5267
Practice Address - Street 1:10600 MASTIN ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-5723
Practice Address - Country:US
Practice Address - Phone:913-681-0606
Practice Address - Fax:913-338-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy