Healthcare Provider Details

I. General information

NPI: 1871803858
Provider Name (Legal Business Name): PRESTON LANE MACKLEY CPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 N FRANKLIN AVE
COLBY KS
67701-2322
US

IV. Provider business mailing address

270 N FRANKLIN AVE
COLBY KS
67701-2322
US

V. Phone/Fax

Practice location:
  • Phone: 785-462-8008
  • Fax: 785-460-8080
Mailing address:
  • Phone: 785-462-8008
  • Fax: 785-460-8080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-01985
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: