Basic Information
| Provider Information | |||||||||
| NPI: | 1912281940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILD PROTECTION RESPONSE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | SUITE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559200 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 E RUSHOLME ST | ||||||||
| Address2: | MOB2, LOWER LEVEL, SUITE 1 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634217160 | ||||||||
| FaxNumber: | 5634217161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2011 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | HARRE | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5634217160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080C0008X | 26138 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Child Abuse Pediatrics |
No ID Information.