Healthcare Provider Details

I. General information

NPI: 1659564664
Provider Name (Legal Business Name): PHYSICAL MEDICINE & REHABILITATION ASSOCIATES OF NORTHEAST IOWA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 W PARK LANE
WATERLOO IA
50701-5178
US

IV. Provider business mailing address

36 W PARK LN
WATERLOO IA
50701-5178
US

V. Phone/Fax

Practice location:
  • Phone: 319-234-0109
  • Fax: 319-234-5774
Mailing address:
  • Phone: 319-234-0109
  • Fax: 319-234-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number27493
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberJ-054600
License Number StateIA

VIII. Authorized Official

Name: DR. FARID F MANSHADI
Title or Position: PRESIDENT
Credential: MD
Phone: 319-234-0109