Provider Demographics
NPI:1104844083
Name:TIME OF YOUR LIFE FITNESS & PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:TIME OF YOUR LIFE FITNESS & PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CARDAMON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:319-354-3824
Mailing Address - Street 1:526 SOUTHGATE AVE
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-4426
Mailing Address - Country:US
Mailing Address - Phone:319-354-3824
Mailing Address - Fax:319-354-3826
Practice Address - Street 1:526 SOUTHGATE AVE
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4426
Practice Address - Country:US
Practice Address - Phone:319-354-3824
Practice Address - Fax:319-354-3826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA34894OtherWELLMARK
IA=========02OtherJOHN DEERE
I10491Medicare ID - Type Unspecified