Healthcare Provider Details

I. General information

NPI: 1083997811
Provider Name (Legal Business Name): MARK LESLIE GEORGOPOULOS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 15TH ST.
ONAWA IA
51040
US

IV. Provider business mailing address

4428 NICOLLET WAY
SIOUX CITY IA
51106-4333
US

V. Phone/Fax

Practice location:
  • Phone: 712-423-2510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001583
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: