Healthcare Provider Details

I. General information

NPI: 1316125818
Provider Name (Legal Business Name): JOHN ANTHONY VIVONA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 W 103RD ST SUITE 300
OVERLAND PARK KS
66214-2642
US

IV. Provider business mailing address

8239 NW BARRYBROOKE CT
KANSAS CITY MO
64151-1057
US

V. Phone/Fax

Practice location:
  • Phone: 913-894-1910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number2001006780
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: