1619379724 NPI number — MELISSA DEE LARSEN

Table of content: RILEY MITCHELL BOYD (NPI 1528543568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619379724 NPI number — MELISSA DEE LARSEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELISSA DEE LARSEN
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:
1619379724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2423 E 9TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50316-1721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-250-4194
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5005 DOUGLAS AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50310-2760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-724-8920
Provider Business Practice Location Address Fax Number:
888-771-3225
Provider Enumeration Date:
09/19/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
DEE
Authorized Official Title or Position:
ARNP
Authorized Official Telephone Number:
515-250-4194

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  G087693 , 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)