1063971166 NPI number — DEVELOPMENTAL WELLNESS

Table of content: (NPI 1063971166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063971166 NPI number — DEVELOPMENTAL WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEVELOPMENTAL WELLNESS
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:
1063971166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4912 WALKER CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50131-2535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-664-3244
Provider Business Mailing Address Fax Number:
844-519-7713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PELLA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50219-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-664-3244
Provider Business Practice Location Address Fax Number:
844-519-7713
Provider Enumeration Date:
03/18/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CERVONE
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CHIEF CLINICAL OFFICER
Authorized Official Telephone Number:
515-664-3422

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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