Provider Demographics
NPI:1942459516
Name:GANU, SURESH (LMT,COMT)
Entity Type:Individual
Prefix:MR
First Name:SURESH
Middle Name:
Last Name:GANU
Suffix:
Gender:M
Credentials:LMT,COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:IA
Mailing Address - Zip Code:52227-0218
Mailing Address - Country:US
Mailing Address - Phone:319-721-0949
Mailing Address - Fax:
Practice Address - Street 1:400 COLLINS ROAD NE
Practice Address - Street 2:ROCKWELL REC. CENTER
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404
Practice Address - Country:US
Practice Address - Phone:319-721-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04048172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA04048OtherMECHANOTHERAPIST -MASSAGE THERAPIST