MEDICARE: STORM LAKE MEDICAL, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1457898801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STORM LAKE MEDICAL, P.C.

Provider Business Mailing Address
First Line	:	801 HUDSON ST
Second Line	:
City	:	STORM LAKE
State	:	IA
Zip	:	50588-2213
Country	:	US
Telephone Number	:	712-213-3349
Fax Number	:	712-732-5493

Provider Business Practice Location Address
First Line	:	801 HUDSON ST
Second Line	:
City	:	STORM LAKE
State	:	IA
Zip	:	50588-2213
Country	:	US
Telephone Number	:	712-213-3349
Fax Number	:	712-732-5493

Authorized Official
Title or Position	:	OWNER
Name	:	MR. TIMOTHY W REDENBAUGH
Credential	:	D.C.
Telephone Number	:	712-732-3349

Provider Enumeration Date	:	01/24/2017
Last Update Date	:	04/30/2022

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