Provider Demographics
NPI:1154610186
Name:EICHENBERGER, GARY DWAYNE (DPT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:DWAYNE
Last Name:EICHENBERGER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 W 75TH ST
Mailing Address - Street 2:STE. 350
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2205
Mailing Address - Country:US
Mailing Address - Phone:913-362-8317
Mailing Address - Fax:913-362-0169
Practice Address - Street 1:102 S FORREST AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1908
Practice Address - Country:US
Practice Address - Phone:515-341-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010031806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO12198273OtherCAQH NUMBER