Basic Information
| Provider Information | |||||||||
| NPI: | 1306965348 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA CLINICA MEDICA LATINA OF DES MOINES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
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| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 DES MOINES ST | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503095502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152658200 | ||||||||
| FaxNumber: | 5152620045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 03/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | EAGLES | ||||||||
| AuthorizedOfficialFirstName: | AVA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC OPERATIONS MGR CO OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5152658200 | ||||||||
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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 | 207R00000X | 25966 | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | A098023 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | DN6229 | 01 | IA | RAILROAD MEDICARE | OTHER | 0785931 | 05 | IA | MEDICAID | 0785956 | 05 | IA | MEDICAID |