Healthcare Provider Details

I. General information

NPI: 1619537578
Provider Name (Legal Business Name): ADVANCED PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 N WOODLAWN BLVD STE D
DERBY KS
67037-2953
US

IV. Provider business mailing address

200 W DOUGLAS AVE STE 1040
WICHITA KS
67202-3017
US

V. Phone/Fax

Practice location:
  • Phone: 316-202-0970
  • Fax: 316-202-0971
Mailing address:
  • Phone: 316-263-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DAVID CHARLES TODD
Title or Position: OWNER
Credential:
Phone: 316-263-0003