1336773696 NPI number — ILLINOIS THERAPY ASSOCIATES LLC

Table of content: (NPI 1336773696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336773696 NPI number — ILLINOIS THERAPY ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS THERAPY ASSOCIATES LLC
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:
6
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:
1336773696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 E BREMER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAVERLY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50677-3435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-231-9446
Provider Business Mailing Address Fax Number:
319-352-4655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WELLNESS OFFICE
Provider Second Line Business Practice Location Address:
941 6TH STREET
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-352-4544
Provider Business Practice Location Address Fax Number:
319-352-4655
Provider Enumeration Date:
02/26/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRITT
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official Telephone Number:
319-352-2726

Provider Taxonomy Codes

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

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