Basic Information
| Provider Information | |||||||||
| NPI: | 1750691572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANTAGE PHYSICAL THERAPY & REHAB, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 7564 HICKMAN ROAD | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503244621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152761111 | ||||||||
| FaxNumber: | 5158640391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2010 | ||||||||
| LastUpdateDate: | 05/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | GOODHUE | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5152761111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 02018 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1750691572 | 05 | IA | MEDICAID | 615606502 | 01 | OWCP | OTHER | DT2836 | 01 | IA | RAILROAD MEDICARE | OTHER |