Healthcare Provider Details

I. General information

NPI: 1265480040
Provider Name (Legal Business Name): DISTAFF PROFESSIONALS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 W JEFFERSON ST
BLOOMFIELD IA
52537-1516
US

IV. Provider business mailing address

PO BOX 67
BLOOMFIELD IA
52537-0067
US

V. Phone/Fax

Practice location:
  • Phone: 641-664-3621
  • Fax: 641-664-3690
Mailing address:
  • Phone: 641-664-3621
  • Fax: 641-664-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DOROTHY CLINE-CAMPBELL
Title or Position: MANAGER
Credential: D.O.
Phone: 641-664-3621