1417044645 NPI number — HEALTHY AGING AND MEMORY CLINIC

Table of content: (NPI 1417044645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417044645 NPI number — HEALTHY AGING AND MEMORY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHY AGING AND MEMORY 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:
1417044645
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2555 106TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANDALE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50322-3766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-334-7524
Provider Business Mailing Address Fax Number:
515-334-7528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 50TH STREET
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
WEST DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-224-4100
Provider Business Practice Location Address Fax Number:
515-224-4926
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENDER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
515-224-4100

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X , with the licence number: 22610 , 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: 2184259 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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