Basic Information
| Provider Information | |||||||||
| NPI: | 1356617757 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLLEGE PARK ANCILLARY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLLEGE PARK PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742554 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134690503 | ||||||||
| FaxNumber: | 9134695267 | ||||||||
| Practice Location | |||||||||
| Address1: | 10600 MASTIN ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662125723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136810606 | ||||||||
| FaxNumber: | 9133381311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 10/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBERS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9134690503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.