Basic Information
| Provider Information | |||||||||
| NPI: | 1982836540 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PCI AUDIOLOGY CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3178 | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524063178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193992022 | ||||||||
| FaxNumber: | 3193992014 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 8TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193992022 | ||||||||
| FaxNumber: | 3193992014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2009 | ||||||||
| LastUpdateDate: | 08/17/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPARENBORG | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3193981563 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIANS' CLINIC OF IOWA, PC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 00550 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 56461 | 01 | IA | GROUP NUMBER | OTHER |