1992784300 NPI number — COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC

Table of content: (NPI 1992784300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992784300 NPI number — COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA 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:
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:
1992784300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1706 WEST AGENCY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BURLINGTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-768-5858
Provider Business Mailing Address Fax Number:
319-753-2301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
951 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMILTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62341-1436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-847-2112
Provider Business Practice Location Address Fax Number:
319-753-2301
Provider Enumeration Date:
01/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLORES
Authorized Official First Name:
ANTONIO
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
319-768-5858

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 506089416 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0563890 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3422957 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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