Healthcare Provider Details

I. General information

NPI: 1922358175
Provider Name (Legal Business Name): VANTAGE REHAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N BROAD ST
SHENANDOAH IA
51601-1318
US

IV. Provider business mailing address

500 N BROAD ST
SHENANDOAH IA
51601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 712-246-2268
  • Fax: 712-246-2110
Mailing address:
  • Phone: 712-246-2268
  • Fax: 712-246-2110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number01774
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier1568643237
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerNPI
# 2
Identifier1811265366
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerNPI

VIII. Authorized Official

Name: LESLI NORDHUES
Title or Position: OWNER/OT
Credential: OT
Phone: 712-303-9948