Provider Demographics
NPI:1548271612
Name:CLINTON PHYSICAL THERAPY SERVICES, P.C.
Entity type:Organization
Organization Name:CLINTON PHYSICAL THERAPY SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANDE KAMP
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:563-357-0305
Mailing Address - Street 1:240 N BLUFF BLVD STE 101
Mailing Address - Street 2:P.O. BOX 337
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-7146
Mailing Address - Country:US
Mailing Address - Phone:563-243-1642
Mailing Address - Fax:563-243-8329
Practice Address - Street 1:240 N BLUFF BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-7146
Practice Address - Country:US
Practice Address - Phone:563-243-1642
Practice Address - Fax:563-243-8329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1271825Medicaid
IA0271825Medicaid
IA0111013OtherMEDICAID DME
IA27182Medicare PIN
IA0271825Medicaid
IA0111013OtherMEDICAID DME
IL211869Medicare PIN