Healthcare Provider Details

I. General information

NPI: 1588952196
Provider Name (Legal Business Name): SHORT PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2011
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 5TH AVE N
HUMBOLDT IA
50548-1105
US

IV. Provider business mailing address

1212 5TH AVE N
HUMBOLDT IA
50548-1105
US

V. Phone/Fax

Practice location:
  • Phone: 515-332-7900
  • Fax: 866-369-7397
Mailing address:
  • Phone: 515-332-7900
  • Fax: 866-369-7397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1455
License Number StateIA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DARYL SHORT
Title or Position: OWNER
Credential: DPT
Phone: 515-332-7900