Provider Demographics
NPI:1558662395
Name:ORTHO SPINE & PAIN CLINIC LLC
Entity type:Organization
Organization Name:ORTHO SPINE & PAIN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUW
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:515-733-2699
Mailing Address - Street 1:2965 E TARPON DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9009
Mailing Address - Country:US
Mailing Address - Phone:515-733-2707
Mailing Address - Fax:515-733-2744
Practice Address - Street 1:618 BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:STORY CITY
Practice Address - State:IA
Practice Address - Zip Code:50248-1255
Practice Address - Country:US
Practice Address - Phone:208-467-9117
Practice Address - Fax:515-733-2744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
004383225100000X
IA0043832251N0400X
2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2047Medicare PIN