Basic Information
| Provider Information | |||||||||
| NPI: | 1659632107 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARINDA YOUTH CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLARINDA ACADEMY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71602 | ||||||||
| Address2: | |||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503250602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152432057 | ||||||||
| FaxNumber: | 5152445570 | ||||||||
| Practice Location | |||||||||
| Address1: | 1820 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | CLARINDA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 516321165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7125423103 | ||||||||
| FaxNumber: | 7125426145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2012 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7125423103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 08601 | IA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 207Q00000X | 29423 | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.