Basic Information
| Provider Information | |||||||||
| NPI: | 1700412848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOME TEAM WELLNESS AND RECOVERY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3038 REDBUD CIR | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500144518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5157084940 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3038 REDBUD CIR | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500144518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5157084940 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2020 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | WYATT | ||||||||
| AuthorizedOfficialFirstName: | GUNNAR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FOUNDER | ||||||||
| AuthorizedOfficialTelephone: | 5157084940 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.P.T. | ||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.