1336357557 NPI number — FAMILY TREE ASSOCIATES, LLC

Table of content: (NPI 1336357557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336357557 NPI number — FAMILY TREE ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY TREE ASSOCIATES, LLC
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:
1336357557
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1947
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50704-1947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-287-5516
Provider Business Mailing Address Fax Number:
319-226-5260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 W 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50702-2845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-287-5516
Provider Business Practice Location Address Fax Number:
319-226-5260
Provider Enumeration Date:
05/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SPEARS
Authorized Official First Name:
RITA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
EXECUTIVE OFFICER
Authorized Official Telephone Number:
319-269-4051

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  29-07-019 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1011379 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 29-07-019 . This is a "RTS SERVICES" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".