Basic Information
| Provider Information | |||||||||
| NPI: | 1154618841 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANQUIST | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 43RD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 3211 DIVISION ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 526011692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3197547899 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2011 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 004179 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 004179 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.