Basic Information
| Provider Information | |||||||||
| NPI: | 1831343656 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL IOWA HEALTHCARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CIH STATE CENTER CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 S 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHALLTOWN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501582998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6417545151 | ||||||||
| FaxNumber: | 6418446208 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 3RD AVE SW | ||||||||
| Address2: | |||||||||
| City: | STATE CENTER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502477719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418442970 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2008 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | WILLIS | ||||||||
| AuthorizedOfficialFirstName: | DAWNETT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ACTING CEO | ||||||||
| AuthorizedOfficialTelephone: | 6417545145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRAL IOWA HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.