1790911626 NPI number — EASTERN IOWA PHYSICAL THERAPY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790911626 NPI number — EASTERN IOWA PHYSICAL THERAPY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN IOWA PHYSICAL THERAPY, PC
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:
1790911626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 688
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52778-0688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-732-4317
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 S MISSISSIPPI ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUE GRASS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52726-9127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-381-8793
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DESSNER
Authorized Official First Name:
BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
563-732-4317

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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