Provider Demographics
NPI:1790818706
Name:HAVEMAN, JOHN S (MPT, ATC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:HAVEMAN
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:J
Other - Middle Name:STEVE
Other - Last Name:HAVEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT, ATC
Mailing Address - Street 1:110 16TH ST SW
Mailing Address - Street 2:
Mailing Address - City:SIOUX CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:51250-2944
Mailing Address - Country:US
Mailing Address - Phone:712-722-1902
Mailing Address - Fax:
Practice Address - Street 1:110 16TH ST SW
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-2944
Practice Address - Country:US
Practice Address - Phone:712-722-1902
Practice Address - Fax:712-722-1905
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI20019Medicare PIN