Healthcare Provider Details

I. General information

NPI: 1134443237
Provider Name (Legal Business Name): TADURAN SPORTS MEDICINE AND OSTEOPATHIC WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E 11TH ST
LIBERAL KS
67901-2784
US

IV. Provider business mailing address

102 E 11TH ST
LIBERAL KS
67901-2784
US

V. Phone/Fax

Practice location:
  • Phone: 620-624-2565
  • Fax:
Mailing address:
  • Phone: 620-624-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number05-34185
License Number StateKS

VIII. Authorized Official

Name: TROY VIRGIL MAYPA TADURAN
Title or Position: OWNER
Credential: D.O.
Phone: 620-624-2565