Healthcare Provider Details

I. General information

NPI: 1588621569
Provider Name (Legal Business Name): TASHA ALICE VORM PTA, LAT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TASHA ALICE BOOCK LAT ATC

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 6TH ST
NEVADA IA
50201
US

IV. Provider business mailing address

PO BOX 461
NEVADA IA
50201-0461
US

V. Phone/Fax

Practice location:
  • Phone: 515-382-7008
  • Fax: 515-382-7171
Mailing address:
  • Phone: 515-382-3366
  • Fax: 515-382-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001444
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number754YY8930
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: