Healthcare Provider Details

I. General information

NPI: 1013224039
Provider Name (Legal Business Name): MR. MICHAEL LEROY VINYARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 AMES STREET
BALDWIN CITY KS
66006
US

IV. Provider business mailing address

1305 WAKARUSA DRIVE
LAWRENCE KS
66049
US

V. Phone/Fax

Practice location:
  • Phone: 785-594-4100
  • Fax: 785-594-2600
Mailing address:
  • Phone: 785-842-3444
  • Fax: 785-842-3410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-02082
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: