Provider Demographics
NPI:1396493102
Name:OSTEOPRACTIC PHYSICAL THERAPY CLINIC OF WICHITA LLC
Entity type:Organization
Organization Name:OSTEOPRACTIC PHYSICAL THERAPY CLINIC OF WICHITA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:316-779-4110
Mailing Address - Street 1:9 N CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2501
Mailing Address - Country:US
Mailing Address - Phone:316-304-1924
Mailing Address - Fax:
Practice Address - Street 1:804 S OLIVER AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2329
Practice Address - Country:US
Practice Address - Phone:316-779-4110
Practice Address - Fax:316-330-7019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-11
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201357980AMedicaid