Provider Demographics
NPI:1568576304
Name:ADVANCE PHYSICAL THERAPY SPORTS
Entity Type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY SPORTS
Other - Org Name:ADVANCE PHYSICAL THERAPY & SPORTS MEDICINE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:REIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-222-6800
Mailing Address - Street 1:225 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-5837
Mailing Address - Country:US
Mailing Address - Phone:319-524-4900
Mailing Address - Fax:319-524-4895
Practice Address - Street 1:225 MAIN ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-5837
Practice Address - Country:US
Practice Address - Phone:319-524-4900
Practice Address - Fax:319-524-4895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty