Basic Information
Provider Information | |||||||||
NPI: | 1528690195 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTURA VENTURES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTURA PHYSICAL THERAPY AT N NEVADA | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 801172 | ||||||||
Address2: |   | ||||||||
City: | KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641801172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009530104 | ||||||||
FaxNumber: | 3037656670 | ||||||||
Practice Location | |||||||||
Address1: | 4925 N NEVADA AVE | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809188600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7197764878 | ||||||||
FaxNumber: | 7197764926 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2020 | ||||||||
LastUpdateDate: | 09/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARPENTER | ||||||||
AuthorizedOfficialFirstName: | DEBRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP, AMBULATORY SERVICES | ||||||||
AuthorizedOfficialTelephone: | 3037656998 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: | 09/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.