Kennan Paavo Archer, D.P.T.
Individual provider Active NPI Physical Therapist · Pella, IA
NPI 1720211642 · NPPES record last updated Mar 14, 2017
Key facts
- NPI
- 1720211642
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physical Therapist 225100000X
- License
- 005021 (IA)
- Practice address
- 405 Monroe St
Pella, IA 50219-1189 - Phone
- (641) 628-6623
- NPI assigned
- Aug 26, 2009
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180103001408 | WI | Practitioner - Physical Therapist in Private Practice | 5890832448 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| The Lakes Community Health Center, Inc | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 005021 | IA | Yes |
Addresses
Primary practice location
405 Monroe St
Pella, IA 50219-1189
Mailing address
405 Monroe St
Pella, IA 50219-1189
Phone (641) 628-6623
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 005021 | Other | IA | IOWA LICENSE |
Other providers in Pella, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 14, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.