=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003326299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CV PHYSICAL THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2017
-----------------------------------------------------
Last Update Date | 01/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1880 RADFORD RD STE 4
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52002-2272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-599-5548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1880 RADFORD RD STE 4
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52002-2272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | CHARITY VANCLEVE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 563-587-8317
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 03815
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------