Provider Demographics
NPI:1609820133
Name:CORE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:CORE PHYSICAL THERAPY INC
Other - Org Name:ADEL PHYSICAL THERAPY INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT MHS OCS
Authorized Official - Phone:515-440-3439
Mailing Address - Street 1:2001 WESTOWN PARKWAY
Mailing Address - Street 2:STE 107
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-1540
Mailing Address - Country:US
Mailing Address - Phone:515-244-0343
Mailing Address - Fax:515-440-3832
Practice Address - Street 1:2001 WESTOWN PARKWAY
Practice Address - Street 2:STE 107
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-1540
Practice Address - Country:US
Practice Address - Phone:515-440-3439
Practice Address - Fax:515-440-3832
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORE PHYSICAL THERAPY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA225100000X, 225X00000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0483784Medicaid
IA0483784Medicaid
I17035Medicare UPIN