Provider Demographics
NPI:1851571814
Name:CLINTON PHYSICAL THERAPY SERVICES
Entity Type:Organization
Organization Name:CLINTON PHYSICAL THERAPY SERVICES
Other - Org Name:MORRISON PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANDE KAMP
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:563-357-0305
Mailing Address - Street 1:635 E LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:IL
Mailing Address - Zip Code:61270-2963
Mailing Address - Country:US
Mailing Address - Phone:815-772-7274
Mailing Address - Fax:815-772-4590
Practice Address - Street 1:635 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:IL
Practice Address - Zip Code:61270-2963
Practice Address - Country:US
Practice Address - Phone:815-772-7274
Practice Address - Fax:815-772-4590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0111013OtherMEDICAID DME
0344680004Medicare NSC