Healthcare Provider Details

I. General information

NPI: 1376966994
Provider Name (Legal Business Name): MAPLE VALLEY - ANTHON OTO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W DIVISION ST
ANTHON IA
51004-8192
US

IV. Provider business mailing address

501 S 7TH ST
MAPLETON IA
51034-1138
US

V. Phone/Fax

Practice location:
  • Phone: 712-881-1315
  • Fax:
Mailing address:
  • Phone: 712-881-1315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: SHONA KLINGENSMITH
Title or Position: BUSINESS MANAGER
Credential:
Phone: 712-373-5246