Healthcare Provider Details

I. General information

NPI: 1447234919
Provider Name (Legal Business Name): GENGASTRO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 03/07/2023
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 53RD AVE
BETTENDORF IA
52722-7546
US

IV. Provider business mailing address

2222 53RD AVE
BETTENDORF IA
52722-7546
US

V. Phone/Fax

Practice location:
  • Phone: 563-383-2686
  • Fax: 563-884-8144
Mailing address:
  • Phone: 563-383-2686
  • Fax: 563-884-8144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateIA

VIII. Authorized Official

Name: MRS. PAIGE TAGUE
Title or Position: LEAD INSURANCE BILLER
Credential:
Phone: 563-383-2686