Healthcare Provider Details

I. General information

NPI: 1720694896
Provider Name (Legal Business Name): BENJAMIN ADAM MORALES PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

834 N SOCORA ST STE 1
WICHITA KS
67212-3279
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 316-440-3731
  • Fax: 316-440-3741
Mailing address:
  • Phone: 316-263-0003
  • Fax: 316-263-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-03766
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: