Basic Information
| Provider Information | |||||||||
| NPI: | 1427345289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILTZ | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12370 S CRESTONE ST | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660616652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137052526 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10000 W 75TH ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138941910 | ||||||||
| FaxNumber: | 9138941174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2011 | ||||||||
| LastUpdateDate: | 06/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11-04265 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.