Basic Information
| Provider Information | |||||||||
| NPI: | 1255095477 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEOPLES COMMUNITY HEALTH CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198743000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1505 LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507031910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194332500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2021 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | HR ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3198743000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEOPLES COMMUNITY HEALTH CLINIC, INC | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 15689 | 01 | IA | WELLMARK BLUE CROSS AND BLUE SHIELD | OTHER | 0076372 | 05 | IA | MEDICAID |