Provider Demographics
NPI:1770754954
Name:MIDWEST THERAPY, CLINTON
Entity type:Organization
Organization Name:MIDWEST THERAPY, CLINTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-327-0132
Mailing Address - Street 1:PO BOX 3488
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52808-3488
Mailing Address - Country:US
Mailing Address - Phone:563-327-0132
Mailing Address - Fax:563-359-5642
Practice Address - Street 1:1820 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52802-1812
Practice Address - Country:US
Practice Address - Phone:563-327-0135
Practice Address - Fax:563-322-2117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRAATEN HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-17
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665828Medicaid
IA166579Medicare Oscar/Certification