1548271612 NPI number — CLINTON PHYSICAL THERAPY SERVICES, P.C.

Table of content: (NPI 1548271612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548271612 NPI number — CLINTON PHYSICAL THERAPY SERVICES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINTON PHYSICAL THERAPY SERVICES, P.C.
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:
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:
1548271612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 N BLUFF BLVD STE 101
Provider Second Line Business Mailing Address:
P.O. BOX 337
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52732-7146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-243-1642
Provider Business Mailing Address Fax Number:
563-243-8329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 N BLUFF BLVD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52732-7146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-243-1642
Provider Business Practice Location Address Fax Number:
563-243-8329
Provider Enumeration Date:
08/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VANDE KAMP
Authorized Official First Name:
GARY
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
563-357-0305

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1271825 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0271825 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0111013 . This is a "MEDICAID DME" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".