1336997014 NPI number — QUEENYEE FAMILY MEDICINE CLINIC

Table of content: (NPI 1336997014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336997014 NPI number — QUEENYEE FAMILY MEDICINE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUEENYEE FAMILY MEDICINE CLINIC
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:
1336997014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
860 22ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORALVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52241-1687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-594-2545
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 22ND AVE REAR UNIT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORALVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52241-1687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-594-2545
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2024

Additional Information

Authorized Official

Authorized Official Last Name:
LI
Authorized Official First Name:
ZHENBO
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN ASSISTANT
Authorized Official Telephone Number:
319-594-2545

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com