Healthcare Provider Details

I. General information

NPI: 1295341758
Provider Name (Legal Business Name): PERFECT FIT FOUNDATION OF SWK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 CENTRAL AVE
DODGE CITY KS
67801-6210
US

IV. Provider business mailing address

PO BOX 1884
DODGE CITY KS
67801-1884
US

V. Phone/Fax

Practice location:
  • Phone: 620-253-2920
  • Fax: 620-371-6570
Mailing address:
  • Phone: 620-253-2920
  • Fax: 620-371-6570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRISTA FERGERSON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 513-490-3643