Basic Information
| Provider Information | |||||||||
| NPI: | 1689041329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NICK HILDRETH MEMORIAL CLINIC, 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: | 5152880122 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 COURT ST | ||||||||
| Address2: | |||||||||
| City: | ROCKWELL CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505791534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5152880122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2015 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | HILDRETH | ||||||||
| AuthorizedOfficialFirstName: | KYLIE | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | ARNP/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5152373974 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.