1376610576 NPI number — CITY OF EVANSDALE

Table of content: (NPI 1376610576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376610576 NPI number — CITY OF EVANSDALE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF EVANSDALE
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:
1376610576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 N EVANS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSDALE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50707-1115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-232-6683
Provider Business Mailing Address Fax Number:
319-232-1586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 S EVANS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSDALE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50707-1647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-233-6930
Provider Business Practice Location Address Fax Number:
319-274-8966
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMOCK
Authorized Official First Name:
KENT
Authorized Official Middle Name:
Authorized Official Title or Position:
AMBULANCE DIRECTOR
Authorized Official Telephone Number:
319-233-6930

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  2070400 , 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: 0093773 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09377 . This is a "BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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