1174900344 NPI number — MRS. LESLIE A KEISTER OTR, MOT

Table of content: MRS. LESLIE A KEISTER OTR, MOT (NPI 1174900344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174900344 NPI number — MRS. LESLIE A KEISTER OTR, MOT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEISTER
Provider First Name:
LESLIE
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR, MOT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174900344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8416 E CRAIG DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67210-1727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-829-6151
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3636 N RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67205-1213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-462-3636
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  17-03014 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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