Provider Demographics
NPI:1811963689
Name:KEINERT, VICTORIA STEVENS (M S P T)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:STEVENS
Last Name:KEINERT
Suffix:
Gender:F
Credentials:M S P T
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LEE
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:123 6TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-6455
Practice Address - Country:US
Practice Address - Phone:515-233-1139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA65-1216836OtherFEDER AL IRS EIN
IAS99349Medicare UPIN