Basic Information
Provider Information | |||||||||
NPI: | 1588621569 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VORM | ||||||||
FirstName: | TASHA | ||||||||
MiddleName: | ALICE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA, LAT ATC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BOOCK | ||||||||
OtherFirstName: | TASHA | ||||||||
OtherMiddleName: | ALICE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LAT ATC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 461 | ||||||||
Address2: |   | ||||||||
City: | NEVADA | ||||||||
State: | IA | ||||||||
PostalCode: | 502010461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5153823366 | ||||||||
FaxNumber: | 5153821576 | ||||||||
Practice Location | |||||||||
Address1: | 630 6TH ST | ||||||||
Address2: |   | ||||||||
City: | NEVADA | ||||||||
State: | IA | ||||||||
PostalCode: | 50201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5153827008 | ||||||||
FaxNumber: | 5153827171 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 08/13/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 754YY8930 | IA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225200000X | 001444 | IA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.