1033289749 NPI number — SPORTS REHAB AND PROFESSIONAL THERAPY ASSOCIATES INC

Table of content: (NPI 1033289749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033289749 NPI number — SPORTS REHAB AND PROFESSIONAL THERAPY ASSOCIATES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS REHAB AND PROFESSIONAL THERAPY ASSOCIATES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SPORTS REHAB & PROFESSIONAL THERAPY
Provider Other Organization Name Type Code:
3
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:
1033289749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 W 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STORM LAKE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50588-1743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-732-7724
Provider Business Mailing Address Fax Number:
712-732-5153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STORM LAKE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50588-1743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-732-7724
Provider Business Practice Location Address Fax Number:
712-560-9253
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GODFREY
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CLINIC ADMIN DIRECTOR
Authorized Official Telephone Number:
402-334-6025

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0665141 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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