Healthcare Provider Details

I. General information

NPI: 1003202045
Provider Name (Legal Business Name): REESA VOLGAMORE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W 21ST ST
ANDOVER KS
67002-8498
US

IV. Provider business mailing address

621 W 21ST ST
ANDOVER KS
67002-8498
US

V. Phone/Fax

Practice location:
  • Phone: 316-733-1349
  • Fax: 316-733-0919
Mailing address:
  • Phone: 316-733-1349
  • Fax: 316-733-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-02420
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: