Healthcare Provider Details

I. General information

NPI: 1134232101
Provider Name (Legal Business Name): TIMOTHY VANDER WILT MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 1ST ST SUITE W270
ANKENY IA
50021-2077
US

IV. Provider business mailing address

PO BOX 1475
DES MOINES IA
50305-1475
US

V. Phone/Fax

Practice location:
  • Phone: 515-643-7555
  • Fax:
Mailing address:
  • Phone: 515-643-7555
  • Fax: 515-643-7560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number03434
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: