Basic Information
| Provider Information | |||||||||
| NPI: | 1730711862 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTURA VENTURES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTURA PHYSICAL THERAPY AT PUEBLO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801172 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009530104 | ||||||||
| FaxNumber: | 3037656670 | ||||||||
| Practice Location | |||||||||
| Address1: | 4112 OUTLOOK BLVD STE 96 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195626200 | ||||||||
| FaxNumber: | 7195626225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2020 | ||||||||
| LastUpdateDate: | 10/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARPENTER | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, AMBULATORY SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3037656998 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | 10/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 1073882197 | 01 | OLD NPI | OTHER | 9000133413 | 05 | CO | MEDICAID |