Basic Information
| Provider Information | |||||||||
| NPI: | 1114963154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 21ST CENTURY REHAB PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 461 | ||||||||
| Address2: | |||||||||
| City: | NEVADA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502010461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153823366 | ||||||||
| FaxNumber: | 5153821576 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 8TH ST SW | ||||||||
| Address2: | |||||||||
| City: | ALTOONA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500094124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159674124 | ||||||||
| FaxNumber: | 5159679094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 02/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | CASSABAUM | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5153823366 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 21ST CENTURY REHAB PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 139763501 | 01 | OWCP FED WC ALTOONA | OTHER | 66554 | 01 | BCBS ALTOONA | OTHER | F1001 | 01 | MIDLANDS | OTHER | 3432608 | 01 | PREMIER PROV NETWK | OTHER | 0665547 | 05 | IA | MEDICAID | 154075 | 01 | IOWA HEALTH SOLUTIONS | OTHER |