Healthcare Provider Details

I. General information

NPI: 1316293624
Provider Name (Legal Business Name): XIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 MAIN ST
ADEL IA
50003-1523
US

IV. Provider business mailing address

707 MAIN STREET
ADEL IA
50003-1523
US

V. Phone/Fax

Practice location:
  • Phone: 515-993-2123
  • Fax: 515-993-2276
Mailing address:
  • Phone: 515-993-2123
  • Fax: 515-993-2276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH R. CLAIBOURN
Title or Position: CEO
Credential:
Phone: 515-993-2123