Basic Information
Provider Information | |||||||||
NPI: | 1922252741 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL IOWA HEALTHCARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CIH CONRAD CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 S 4TH AVE | ||||||||
Address2: |   | ||||||||
City: | MARSHALLTOWN | ||||||||
State: | IA | ||||||||
PostalCode: | 501582998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6417545151 | ||||||||
FaxNumber: | 6418446208 | ||||||||
Practice Location | |||||||||
Address1: | 105 N CHURCH ST | ||||||||
Address2: |   | ||||||||
City: | CONRAD | ||||||||
State: | IA | ||||||||
PostalCode: | 506217714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6413662123 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2008 | ||||||||
LastUpdateDate: | 04/05/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIS | ||||||||
AuthorizedOfficialFirstName: | DAWNETT | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | ACTING CEO | ||||||||
AuthorizedOfficialTelephone: | 6417545145 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTRAL IOWA HEALTHCARE | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.