1205132123 NPI number — IOWA SPEECH THERAPY, LLC

Table of content: (NPI 1205132123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205132123 NPI number — IOWA SPEECH THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IOWA SPEECH THERAPY, 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:
1205132123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANAMOSA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52205-0425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-533-2916
Provider Business Mailing Address Fax Number:
319-462-0546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ANAMOSA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52205-1871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-533-2916
Provider Business Practice Location Address Fax Number:
319-462-0546
Provider Enumeration Date:
02/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SUTHERLAND
Authorized Official First Name:
JACKIE
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
SPEECH-LANGUAGE PATHOLOGIST/OWNER
Authorized Official Telephone Number:
319-533-2916

Provider Taxonomy Codes

  • Taxonomy code: 261QH0700X , with the licence number:  001793 , 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: IB1873 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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