Healthcare Provider Details

I. General information

NPI: 1245323831
Provider Name (Legal Business Name): PT WEST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S MAIN
GORDON NE
69343-1618
US

IV. Provider business mailing address

PO BOX 28 100 SOUTH MAIN
GORDON NE
69343-1618
US

V. Phone/Fax

Practice location:
  • Phone: 308-282-0203
  • Fax: 308-282-1276
Mailing address:
  • Phone: 308-282-0203
  • Fax: 308-282-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number651
License Number StateNE

VIII. Authorized Official

Name: KIMBERLY J MARLATT
Title or Position: PRESIDENT
Credential: PT ATC
Phone: 308-282-0203