1306077490 NPI number — PATRICIA K STARK

Table of content: (NPI 1306077490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306077490 NPI number — PATRICIA K STARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATRICIA K STARK
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:
KILLEAN AUDIOLOGY & HEARING AID CENTER
Provider Other Organization Name Type Code:
3
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:
1306077490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 52ND AVE
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61265-6389
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-762-6467
Provider Business Mailing Address Fax Number:
309-762-7218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 4TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52732-4311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-242-7852
Provider Business Practice Location Address Fax Number:
563-242-0452
Provider Enumeration Date:
08/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
STARK
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
563-242-7852

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  0033 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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