Provider Demographics
NPI:1790674802
Name:WESTERN LEGACY PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:WESTERN LEGACY PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:FAIRBANK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:602-855-6060
Mailing Address - Street 1:PO BOX 389
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:KS
Mailing Address - Zip Code:67835-0389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 WEST AVENUE A
Practice Address - Street 2:
Practice Address - City:CIMARRON
Practice Address - State:KS
Practice Address - Zip Code:67835
Practice Address - Country:US
Practice Address - Phone:620-855-6060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy