1932287570 NPI number — COUNTRY CLINICS, PC

Table of content: (NPI 1932287570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932287570 NPI number — COUNTRY CLINICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY CLINICS, PC
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:
CEDAR RAPIDS MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1932287570
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 313
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68627-0313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-358-0615
Provider Business Mailing Address Fax Number:
308-358-0617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 S 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-358-0615
Provider Business Practice Location Address Fax Number:
308-358-0617
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
LISA
Authorized Official Middle Name:
LYNNE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
402-678-2232

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025570600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025570700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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