Basic Information
Provider Information | |||||||||
NPI: | 1316125818 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VIVONA | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | ANTHONY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8239 NW BARRYBROOKE CT | ||||||||
Address2: |   | ||||||||
City: | KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641511057 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10300 W 103RD ST | ||||||||
Address2: | SUITE 300 | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 662142642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9138941910 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2008 | ||||||||
LastUpdateDate: | 02/06/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225500000X | 2001006780 | MO | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist |   |
ID Information
ID | Type | State | Issuer | Description | 2001006780 | 01 | MO | STATE LICENSE | OTHER |