Basic Information
| Provider Information | |||||||||
| NPI: | 1922279439 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREVENTATIVE HEALTH CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 2480 BERKSHIRE PKWY | ||||||||
| Address2: | |||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503254678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152252578 | ||||||||
| FaxNumber: | 5152252598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 12/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | WHETRO | ||||||||
| AuthorizedOfficialFirstName: | ANGELIA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | MED DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5152252578 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001132 | IA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 111N00000X | 007026 | IA | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 207Q00000X | 03475 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.