1043282759 NPI number — KEVIN WAYNE MACE DO

Table of content: BETSY ZAMORA (NPI 1295157816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043282759 NPI number — KEVIN WAYNE MACE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACE
Provider First Name:
KEVIN
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1043282759
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1208 N LINCOLN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50138-3421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-828-3832
Provider Business Mailing Address Fax Number:
641-828-3820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1208 N LINCOLN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50138-3421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-828-3832
Provider Business Practice Location Address Fax Number:
641-828-3820
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  3542 , 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: 1043282759 . This is a "NPI NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 3440446 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5440446 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00210325 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 4440446 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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