1891771663 NPI number — MMSC VENTURES INC

Table of content: (NPI 1891771663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891771663 NPI number — MMSC VENTURES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMSC VENTURES INC
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:
STATE CENTER FAMILY MEDICINE CLINIC
Provider Other Organization Name Type Code:
3
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:
1891771663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 SOUTH 4TH AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHALLTOWN
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50158-2998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-754-5151
Provider Business Mailing Address Fax Number:
641-754-5181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 3RD AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATE CENTER
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50247-7719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-483-2141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DOWNEY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
641-754-5125

Provider Taxonomy Codes

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

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

  • Identifier: 0685214 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47411 . This is a "BLUE SHIELD OF IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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