Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2019-12-31
- Last updated
- 2023-09-25
Specialties
Licenses
- License IA
- 23111
Location
- Practice location
- 400 N ELM ST
- City
- JEFFERSON IA
- Postal code
- 501291420
- Phone
- 515-386-2164
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.