1194057505 NPI number — GRONDEL URGENT CARE OF HENDERSON, PLLC

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 1194057505 NPI number — GRONDEL URGENT CARE OF HENDERSON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRONDEL URGENT CARE OF HENDERSON, PLLC
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:
1194057505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 629
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTOONA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50009-0629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-645-9911
Provider Business Mailing Address Fax Number:
515-967-5581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10561 JEFFREYS ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89052-4266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-478-5620
Provider Business Practice Location Address Fax Number:
702-478-5093
Provider Enumeration Date:
02/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BRUINSMA
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
616-293-4769

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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