1396103685 NPI number — COUNTRYSIDE MEDICAL CLINIC, LLC

Table of content: MAKENZIE KOON (NPI 1073292975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396103685 NPI number — COUNTRYSIDE MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRYSIDE MEDICAL CLINIC, 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1396103685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1959 200TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED OAK
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51566-3218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-629-0040
Provider Business Mailing Address Fax Number:
712-566-5049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1959 200TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED OAK
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51566-3218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-629-0040
Provider Business Practice Location Address Fax Number:
712-566-5049
Provider Enumeration Date:
02/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RINES
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
712-629-0040

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)





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