MEDICARE: BRANT DAVID LOOSE D.P.T

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	11-04252	KS

General Provider Information

NPI Number	:	1518252089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANT DAVID LOOSE D.P.T

Provider Business Mailing Address
First Line	:	7399 W 97TH ST
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66212-2210
Country	:	US
Telephone Number	:	913-649-9090
Fax Number	:	913-649-9091

Provider Business Practice Location Address
First Line	:	7399 W 97TH ST
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66212-2210
Country	:	US
Telephone Number	:	913-649-9090
Fax Number	:	913-649-9091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2011
Last Update Date	:	06/15/2011

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