MEDICARE: DOMINIC THIELEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT-4458	ID
2	225100000X	Physical Therapist	083240	IA

General Provider Information

NPI Number	:	1316397144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC THIELEN

Provider Business Mailing Address
First Line	:	1215 DUFF AVE
Second Line	:
City	:	AMES
State	:	IA
Zip	:	50010-5469
Country	:	US
Telephone Number	:	515-239-4400
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 W WASHINGTON ST STE 2
Second Line	:
City	:	JEFFERSON
State	:	IA
Zip	:	50129-1920
Country	:	US
Telephone Number	:	515-386-4192
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2016
Last Update Date	:	12/16/2021

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Directions to “ DOMINIC THIELEN ” Practice Location

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