1255868360 NPI number — ON WITH LIFE, INC

Table of content: (NPI 1255868360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255868360 NPI number — ON WITH LIFE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ON WITH LIFE, 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:
1255868360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 SW ANKENY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANKENY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50023-9798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-289-9658
Provider Business Mailing Address Fax Number:
515-965-1186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
692 NW 43RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-965-6860
Provider Business Practice Location Address Fax Number:
515-289-1492
Provider Enumeration Date:
05/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
EWALD
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
515-289-9658

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: 0651638 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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