1538122437 NPI number — BACK CARE OF SPIRIT LAKE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538122437 NPI number — BACK CARE OF SPIRIT LAKE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK CARE OF SPIRIT LAKE, INC.
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:
1538122437
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2309 23RD ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPIRIT LAKE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51360-0342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-336-5320
Provider Business Mailing Address Fax Number:
712-336-0020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2309 23RD ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPIRIT LAKE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51360-0342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-336-5320
Provider Business Practice Location Address Fax Number:
712-336-0020
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHELL
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
712-336-5311

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0496174 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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