Healthcare Provider Details

I. General information

NPI: 1992636054
Provider Name (Legal Business Name): CALVIN RICHARD BRUTUS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 LINCOLN ST NE
LE MARS IA
51031
US

IV. Provider business mailing address

512 6TH AVE SE
LE MARS IA
51031
US

V. Phone/Fax

Practice location:
  • Phone: 712-546-4101
  • Fax:
Mailing address:
  • Phone: 863-781-4621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number083506
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: