MEDICARE: EASTERN IOWA THERAPEUTICS P.C.

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

General Provider Information

NPI Number	:	1578128161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN IOWA THERAPEUTICS P.C.

Provider Business Mailing Address
First Line	:	600 OAKMONT LN STE 600C
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-5548
Country	:	US
Telephone Number	:	630-575-6250
Fax Number	:

Provider Business Practice Location Address
First Line	:	314 S MADISON ST
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52240-3841
Country	:	US
Telephone Number	:	319-248-0373
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	JUANA GRANADOS
Credential	:
Telephone Number	:	630-575-1980

Provider Enumeration Date	:	05/08/2019
Last Update Date	:	05/08/2019

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