Basic Information
| Provider Information | |||||||||
| NPI: | 1871601518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELY | ||||||||
| FirstName: | KAREN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152227350 | ||||||||
| FaxNumber: | 5152227355 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 NW 114TH ST | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152227350 | ||||||||
| FaxNumber: | 5152227350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 04/15/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 00297 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3430850 | 05 | IA | MEDICAID |