1205990223 NPI number — THE LARRABEE CENTER, IN.C

Table of content: MS. CYNTHIA DE LEON FUENTES (NPI 1518277656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205990223 NPI number — THE LARRABEE CENTER, IN.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE LARRABEE CENTER, IN.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:
1205990223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 11TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAVERLY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50677-2212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-352-2234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 11TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAVERLY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50677-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-352-2234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILHARM
Authorized Official First Name:
CLARK
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
319-352-2234

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0163428 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0225987 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1225987 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0746859 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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