Provider Demographics
NPI:1073656674
Name:PHYSICAL THERAPY SERVICES PC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-656-3177
Mailing Address - Street 1:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:KALONA
Mailing Address - State:IA
Mailing Address - Zip Code:52247-0535
Mailing Address - Country:US
Mailing Address - Phone:319-656-3177
Mailing Address - Fax:319-656-5241
Practice Address - Street 1:423 B AVE
Practice Address - Street 2:
Practice Address - City:KALONA
Practice Address - State:IA
Practice Address - Zip Code:52247-0535
Practice Address - Country:US
Practice Address - Phone:319-656-3177
Practice Address - Fax:319-656-5241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0423475Medicaid
IAI5413Medicare ID - Type Unspecified