Kelly Waack, DPT

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

085689 Issued in IA

Practice address

850 43Rd Ave
Suite 100
Moline, IL 61265-8401

Phone

(309) 743-2070

Fax

(309) 743-2073

NPI assigned

Jan 18, 2017

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Kelly Divita Former name

Medicare fee-for-service enrollment

Enrolled in IA

Enrollment records 1

Specialty

Physical Therapist in Private Practice

Education

Other, 2016

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Rock Valley Physical Therapy CenterGroup PAC ID 9638087877, 232 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Rock Valley Physical Therapy Center

  • Physical Therapist
  • Moline, IL
  • NPI 1245373166

  IA

  Medicare reassignment Care Compare group NPD
• Rock Valley Physical Therapy Center

  • Occupational Therapist
  • Eldridge, IA
  • NPI 1881540490

  Physical Therapist

  NPD
• Ora Orthopedics, PC

  • Orthopaedic Surgery Physician
  • Durant, IA
  • NPI 1639159700
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1484697600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1544572800000",
    "number": "1811433576",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "850 43RD AVE",
            "address_2": "SUITE 100",
            "city": "MOLINE",
            "state": "IL",
            "postal_code": "612658401",
            "telephone_number": "309-743-2070",
            "fax_number": "309-743-2073"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "850 43RD AVE",
            "address_2": "SUITE 100",
            "city": "MOLINE",
            "state": "IL",
            "postal_code": "612658401",
            "telephone_number": "309-743-2070",
            "fax_number": "309-743-2073"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAACK",
        "first_name": "KELLY",
        "credential": "DPT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-01-18",
        "last_updated": "2018-12-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "IA",
            "license": "085689",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "DIVITA",
            "credential": "DPT",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Wal-Mart Stores, Inc (Vision Center 30-2231)
• Walgreen Co (Walgreens #03633)
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• Walgreen Co (Walgreens #06067)

• Physical Therapist in Moline, IL
• Providers in Moline, IL by specialty
• Physical Therapist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.