Basic Information
| Provider Information | |||||||||
| NPI: | 1457073041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEREMIAH | ||||||||
| FirstName: | LANE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2006 BROOKHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729215012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797394485 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 SOUTHWEST BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641082019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168421146 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2022 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | CP014856T | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5015 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.