1639231814 NPI number — CHOICE MEDICAL, LLC

Table of content: (NPI 1639231814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639231814 NPI number — CHOICE MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOICE MEDICAL, 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:
1639231814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2117 PHILADELPHIA ST
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
AMES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50010-8775
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-232-6000
Provider Business Mailing Address Fax Number:
515-232-2600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2117 PHILADELPHIA ST
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
AMES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50010-8775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-232-6000
Provider Business Practice Location Address Fax Number:
515-232-2600
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENNING
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
515-232-6000

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0262709 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46080 . This is a "WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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