Provider Demographics
NPI:1285772970
Name:SPORTS REHAB & PROFESSIONAL THERAPY ASSOCIATES
Entity type:Organization
Organization Name:SPORTS REHAB & PROFESSIONAL THERAPY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:D
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:712-732-7725
Mailing Address - Street 1:315 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-1743
Mailing Address - Country:US
Mailing Address - Phone:712-732-7725
Mailing Address - Fax:712-732-5153
Practice Address - Street 1:315 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1743
Practice Address - Country:US
Practice Address - Phone:712-732-7725
Practice Address - Fax:712-732-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAM096051332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0118984Medicaid
IA0118984Medicaid