Healthcare Provider Details

I. General information

NPI: 1760540926
Provider Name (Legal Business Name): MATCH PLAY TENNIS CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 COLLINS RD NE BLDG 154-100
CEDAR RAPIDS IA
52498-0001
US

IV. Provider business mailing address

400 COLLINS RD NE BLDG 154-100
CEDAR RAPIDS IA
52498-0001
US

V. Phone/Fax

Practice location:
  • Phone: 319-295-8899
  • Fax: 319-295-8833
Mailing address:
  • Phone: 319-295-8899
  • Fax: 319-295-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberNA
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1066154
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerUSAMCO GROUP NUMBER
# 2
Identifier37850
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK GROUP NUMBER
# 3
IdentifierF245873
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerMIDLANDS CHOICE ID NUMBER
# 4
Identifier5747352
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerFIRST HEALTH GROUP NUMBER

VIII. Authorized Official

Name: PAMELA W FOX
Title or Position: MANAGER
Credential:
Phone: 319-295-8899