Provider Demographics
NPI:1295213007
Name:DEBOER, SAMUEL RICHARD JAMES (DPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RICHARD JAMES
Last Name:DEBOER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-2716
Mailing Address - Country:US
Mailing Address - Phone:319-939-3810
Mailing Address - Fax:
Practice Address - Street 1:312 9TH ST SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2929
Practice Address - Country:US
Practice Address - Phone:319-352-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA092492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist