Basic Information
| Provider Information | |||||||||
| NPI: | 1487109781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOIVUNIEMI-BERG | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | STONE | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10000 W 75TH ST | ||||||||
| Address2: | STE. 250 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889131910 | ||||||||
| FaxNumber: | 8779131174 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 W 75TH ST | ||||||||
| Address2: | STE. 250 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889131910 | ||||||||
| FaxNumber: | 8779131174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2016 | ||||||||
| LastUpdateDate: | 08/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12473 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.