Healthcare Provider Details

I. General information

NPI: 1477808533
Provider Name (Legal Business Name): PROVIDENCE THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 N 2ND ST
CLINTON IA
52732-2434
US

IV. Provider business mailing address

2320 N 2ND ST
CLINTON IA
52732-2434
US

V. Phone/Fax

Practice location:
  • Phone: 563-243-2285
  • Fax: 563-243-2293
Mailing address:
  • Phone: 563-243-2285
  • Fax: 563-243-2293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number00085
License Number StateIA

VIII. Authorized Official

Name: GENA HUMMEL
Title or Position: OFFICE MANAGER - BILLING
Credential:
Phone: 563-242-1170