1740232842 NPI number — CRESTON MEDICAL CLINIC, P.C.

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 1740232842 NPI number — CRESTON MEDICAL CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTON MEDICAL CLINIC, P.C.
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:
1740232842
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1610 W TOWNLINE ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CRESTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50801-1066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-782-2131
Provider Business Mailing Address Fax Number:
641-782-6425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 W TOWNLINE ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CRESTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50801-1066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-782-2131
Provider Business Practice Location Address Fax Number:
641-782-6425
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANSOUR
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT OF THE CORPORATION
Authorized Official Telephone Number:
641-782-2131

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01353 . This is a "WELLMARK BCBS GROUP #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: C54555 . This is a "RAILROAD GROUP BILLING #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 01353 . This is a "WELLMARK BCBS #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0013532 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com