Basic Information
| Provider Information | |||||||||
| NPI: | 1265623128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLEINENDORST | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155152445 | ||||||||
| FaxNumber: | 5152442202 | ||||||||
| Practice Location | |||||||||
| Address1: | 3310 SW 9TH ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503157647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152445005 | ||||||||
| FaxNumber: | 5152442202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 004047 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 70255 | 01 | IA | WELLMARK BLUE SHIELD | OTHER | 1265623128 | 05 | IA | MEDICAID |