1093889644 NPI number — CITY OF EAGLE GROVE

Table of content: (NPI 1093889644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093889644 NPI number — CITY OF EAGLE GROVE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF EAGLE GROVE
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:
6
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:
1093889644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 165
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE GROVE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50533-0165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-448-4686
Provider Business Mailing Address Fax Number:
515-448-3761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 E BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE GROVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50533-1813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-448-4686
Provider Business Practice Location Address Fax Number:
515-448-3761
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MADSON
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
EMS DIRECTOR
Authorized Official Telephone Number:
515-448-4686

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  2990300 , 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: 0057059 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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