Healthcare Provider Details

I. General information

NPI: 1285772970
Provider Name (Legal Business Name): SPORTS REHAB & PROFESSIONAL THERAPY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 5TH ST
STORM LAKE IA
50588-1743
US

IV. Provider business mailing address

315 W 5TH ST
STORM LAKE IA
50588-1743
US

V. Phone/Fax

Practice location:
  • Phone: 712-732-7725
  • Fax: 712-732-5153
Mailing address:
  • Phone: 712-732-7725
  • Fax: 712-732-5153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberM096051
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberM096051
License Number StateIA

VIII. Authorized Official

Name: MR. TODD D NICHOLSON
Title or Position: PRESIDENT PHYSICAL THERAPIST
Credential: PHYSICAL THERAPIST
Phone: 712-732-7725