Basic Information
| Provider Information | |||||||||
| NPI: | 1790854701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELROY | ||||||||
| FirstName: | BRENT | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12112 W KELLOGG ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672351100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3164401100 | ||||||||
| FaxNumber: | 3164401089 | ||||||||
| Practice Location | |||||||||
| Address1: | 4940 W. 137TH ST. | ||||||||
| Address2: | |||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662246622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132329846 | ||||||||
| FaxNumber: | 9132329817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 2251X0800X | 11-03653 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 200429520B | 05 | KS | MEDICAID | 11-03653 | 01 | KS | PT LICENSE | OTHER |