Provider Demographics
NPI:1669532388
Name:PROVIDENCE THERAPY SERVICES LLC
Entity type:Organization
Organization Name:PROVIDENCE THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GILLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-359-4054
Mailing Address - Street 1:21037 HOLDEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804
Mailing Address - Country:US
Mailing Address - Phone:563-359-4054
Mailing Address - Fax:563-359-4084
Practice Address - Street 1:21037 HOLDEN DRIVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804
Practice Address - Country:US
Practice Address - Phone:563-359-4054
Practice Address - Fax:563-359-4084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0474460Medicaid
I13353Medicare ID - Type Unspecified