Provider Demographics
NPI:1457778870
Name:CONCENTRA
Entity Type:Organization
Organization Name:CONCENTRA
Other - Org Name:CONCENTRA URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WHITACRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-571-1104
Mailing Address - Street 1:3540 E 46TH STREET
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-359-1170
Mailing Address - Fax:
Practice Address - Street 1:3540 E 46TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-359-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCENTRA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01242251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization