Provider Demographics
NPI:1477808533
Name:PROVIDENCE THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:PROVIDENCE THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER - BILLING
Authorized Official - Prefix:
Authorized Official - First Name:GENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-242-1170
Mailing Address - Street 1:2320 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-2434
Mailing Address - Country:US
Mailing Address - Phone:563-243-2285
Mailing Address - Fax:563-243-2293
Practice Address - Street 1:2320 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2434
Practice Address - Country:US
Practice Address - Phone:563-243-2285
Practice Address - Fax:563-243-2293
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE THERAPY SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-16
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00085225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2561Medicare UPIN