Basic Information
| Provider Information | |||||||||
| NPI: | 1720278278 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY HEALTH CARE OF SIOUXLAND LLC | ||||||||
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| OtherOrganizationName: | FAMILY HEALTH CARE MOVILLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 PIERCE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122262600 | ||||||||
| FaxNumber: | 7122262605 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510397715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7128735225 | ||||||||
| FaxNumber: | 7128735206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCCABE-HARDING | ||||||||
| AuthorizedOfficialFirstName: | SHANIN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7122262600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 163890 | 01 | IA | MEDICARE RIVERBEND GOVERN | OTHER | 0263913 | 05 | IA | MEDICAID |