Basic Information
| Provider Information | |||||||||
| NPI: | 1174783583 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 21ST CENTURY REHAB,PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INDIANOLA PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1507 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | INDIANOLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501253703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159617435 | ||||||||
| FaxNumber: | 5159617436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 07/17/2008 | ||||||||
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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 | IA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0665810 | 05 | IA | MEDICAID | 36587 | 01 | IA | WELLMARK BCBS | OTHER |