Provider Demographics
NPI:1083963037
Name:INTEGRATED PHYSICAL THERAPY AND SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:INTEGRATED PHYSICAL THERAPY AND SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TATE
Authorized Official - Middle Name:C
Authorized Official - Last Name:VAN HOUTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:515-288-0569
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:1515 LINDEN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-3120
Practice Address - Country:US
Practice Address - Phone:515-288-0569
Practice Address - Fax:515-288-0347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIN PROCESSMedicaid
IAIN PROCESSMedicare PIN