1528705050 NPI number — DR. JOHN WALTER LACE PHD

Table of content: DR. JOHN WALTER LACE PHD (NPI 1528705050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528705050 NPI number — DR. JOHN WALTER LACE PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LACE
Provider First Name:
JOHN
Provider Middle Name:
WALTER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1528705050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1026 A AVE NE
Provider Second Line Business Mailing Address:
PMR - NEUROPSYCHOLOGY
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-369-7211
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1026 A AVE NE
Provider Second Line Business Practice Location Address:
PMR - NEUROPSYCHOLOGY
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-369-7211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2022

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: 103G00000X , with the licence number:  110965 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103G00000X , with the licence number: 5000-57 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 5000-57 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0100X , with the licence number: 126559 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 110965 , 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)