Basic Information
Provider Information | |||||||||
NPI: | 1629684709 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEOPLES COMMUNITY HEALTH CLINIC, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 905 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507034407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3198743000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 425 1/2 EAST RIDGEWAY AVE. | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 50702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3194332780 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2020 | ||||||||
LastUpdateDate: | 09/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITE | ||||||||
AuthorizedOfficialFirstName: | BETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | HR ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3198743429 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PEOPLES COMMUNITY HEALTH CLINIC, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/21/2020 |
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 | 0076372 | 05 | IA |   | MEDICAID | 15689 | 01 | IA | WELLMARK BCBS | OTHER |