Provider Demographics
NPI:1073875779
Name:WEST DES MOINES PHYSICAL THERAPY AND SPORTS REHABILITATION, PLLC
Entity Type:Organization
Organization Name:WEST DES MOINES PHYSICAL THERAPY AND SPORTS REHABILITATION, PLLC
Other - Org Name:WEST DES MOINES PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:515-771-8779
Mailing Address - Street 1:517 COLONIAL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-3733
Mailing Address - Country:US
Mailing Address - Phone:515-771-8779
Mailing Address - Fax:
Practice Address - Street 1:3701 EP TRUE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-7696
Practice Address - Country:US
Practice Address - Phone:515-480-8038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-09
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4657225100000X
IA4589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty