Basic Information
| Provider Information | |||||||||
| NPI: | 1407016819 | ||||||||
| 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: | 209 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MADRID | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501561211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5157952427 | ||||||||
| FaxNumber: | 5157952482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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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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| NPICertificationDate: | 08/05/2022 | ||||||||
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 | 66559 | 01 | IA | WELLMARK BCBS | OTHER | 0665596 | 05 | IA | MEDICAID |