Healthcare Provider Details

I. General information

NPI: 1083269856
Provider Name (Legal Business Name): CASEY CANTWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20911 W 153RD ST
OLATHE KS
66061-6219
US

IV. Provider business mailing address

1040 W FAIRWOOD LN
OLATHE KS
66061-2414
US

V. Phone/Fax

Practice location:
  • Phone: 920-342-0466
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number14-03400
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-03400
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: