1477505915 NPI number — SHELL ROCK FAMILY HEALTH LLC

Table of content: (NPI 1477505915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477505915 NPI number — SHELL ROCK FAMILY HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELL ROCK FAMILY HEALTH 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477505915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50704-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-233-3044
Provider Business Mailing Address Fax Number:
319-233-0722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
513 NORTH CHERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELL ROCK
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-885-6530
Provider Business Practice Location Address Fax Number:
319-885-6535
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SKIERKA
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
319-885-6530

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10315 . This is a "BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com