Basic Information
| Provider Information | |||||||||
| NPI: | 1124307129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACKLEY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | A DEPARTMENT OF ELLSWORTH HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | ACKLEY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506011701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | ACKLEY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506011701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418472625 | ||||||||
| FaxNumber: | 6418472509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2011 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEDERHOFF | ||||||||
| AuthorizedOfficialFirstName: | DARLA | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6418472625 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELLSWORTH MUNICIPAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 118827 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 118827 | 01 | IA | LICENSE NUMBER | OTHER |