Basic Information
| Provider Information | |||||||||
| NPI: | 1235183419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANSON FAMILY HEALTH INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | MANSON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505635065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124693307 | ||||||||
| FaxNumber: | 7124692614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | LEPPERT | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7124693307 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ARNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 168947 | 01 | IA | MEDICARE RURAL HEALTH PIN | OTHER | 0425082 | 05 | IA | MEDICAID | DD8904 | 01 | IA | RAILROAD MEDICARE PIN | OTHER |