1841263233 NPI number — MEDICAL CLINIC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841263233 NPI number — MEDICAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL CLINIC 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:
6
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:
1841263233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1219 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMBURG
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51640-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-382-2626
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TABOR
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51653-2069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-629-2975
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKSON
Authorized Official First Name:
CRISTIN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
712-382-1515

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0018507 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13034 . This is a "WELLMARK BC/BS OF IA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0638361 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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