17D2301357 CLIA NUMBER - AT PROVIDER GROUP OF KANSAS, PA

Laboratory Demographics

CLIA Number: 17D2301357

Facility Name: AT PROVIDER GROUP OF KANSAS, PA

Facility Address:
9393 WEST 110TH ST, SUITE 500, OFFICE 545
OVERLAND PARK, KS
ZIP 66210
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Facility Phone Number: 845 769-8758

Facility Type: Comp. Outpatient Rehab Facility

Certificate Type: Waiver

NPI Number: 1700580305

Taxonomy: 261QR0405X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	17D2301357
LAB Type	Comp. Outpatient Rehab Facility
Facility Name	AT PROVIDER GROUP OF KANSAS, PA
Street	9393 WEST 110TH ST, SUITE 500, OFFICE 545
City	OVERLAND PARK
State	KS
ZIP	66210
Phone	845 769-8758
CertificateType	4
CertificateEffectiveDate	3/25/2024
CertificateExpirationDate	3/24/2026
FacilityType	Waiver

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This page was last updated on: 4/23/2024