1760590046 NPI number — CHILD HEALTH SPECIALTY CLINICS

Table of content: (NPI 1760590046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760590046 NPI number — CHILD HEALTH SPECIALTY CLINICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILD HEALTH SPECIALTY CLINICS
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:
1760590046
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 HAWKINS DR.
Provider Second Line Business Mailing Address:
247-A CDD
Provider Business Mailing Address City Name:
IOWA CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-384-6674
Provider Business Mailing Address Fax Number:
319-356-3715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 HAWKINS DR.
Provider Second Line Business Practice Location Address:
247-A CDD
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-384-6674
Provider Business Practice Location Address Fax Number:
319-356-3715
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHUELKE
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
GRANTS & CONTRACT MANAGER
Authorized Official Telephone Number:
319-384-6674

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0736264 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053503755 . This is a "NPI" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0734871 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0797431 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0480202 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1609915628 . This is a "NPI" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1225177579 . This is a "NPI" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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