1003813908 NPI number — AMENITY HEALTHCARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003813908 NPI number — AMENITY HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMENITY HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003813908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 CADILLAC DR
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-425-5407
Provider Business Mailing Address Fax Number:
615-373-4457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5005 BOWLING ST SW STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52404-5070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-362-2500
Provider Business Practice Location Address Fax Number:
319-362-2501
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ADKINS
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP GENERAL COUNSEL
Authorized Official Telephone Number:
615-309-5668

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  STATE DOES NOT ISSUE , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7251528 . This is a "AETNA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0615716 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61566 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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