1417785551 NPI number — MRS. ELLEN ANNE LANTZ RD, LD

Table of content: MRS. ELLEN ANNE LANTZ RD, LD (NPI 1417785551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417785551 NPI number — MRS. ELLEN ANNE LANTZ RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANTZ
Provider First Name:
ELLEN
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LANTZ
Provider Other First Name:
ELLEN
Provider Other Middle Name:
TREY
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, LD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417785551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
59364 210TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMEROY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50575-8032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-358-0038
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 KENYON ROAD
Provider Second Line Business Practice Location Address:
TRINITY REGIONAL MEDICAL CENTER NUTRITIONAL SERVICES
Provider Business Practice Location Address City Name:
FORT DODGE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-358-0038
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  00515 , 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)