Healthcare Provider Details

I. General information

NPI: 1790140234
Provider Name (Legal Business Name): SPORTSPLUS PHYSICAL THERAPY GC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 E 1ST ST
GRUNDY CENTER IA
50638
US

IV. Provider business mailing address

606 E 1ST ST
GRUNDY CENTER IA
50638-2046
US

V. Phone/Fax

Practice location:
  • Phone: 319-825-6636
  • Fax: 319-825-4939
Mailing address:
  • Phone: 319-825-6636
  • Fax: 319-825-4939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SCOTT CARNAHAN
Title or Position: DIRECTOR
Credential:
Phone: 319-825-6636