=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790214252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE PT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2017
-----------------------------------------------------
Last Update Date | 09/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 S FORREST AVE
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-341-2721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8305 NE 105TH ST
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64157-9102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/ OWNER
-----------------------------------------------------
Name | DR. GARY DWAYNE EICHENBERGER
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 515-341-2721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------