Healthcare Provider Details

I. General information

NPI: 1568603611
Provider Name (Legal Business Name): AMBROSE B EARLE JR. M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N 9TH ST #8
CARLISLE IA
50047-7685
US

IV. Provider business mailing address

630 N 9TH ST #8
CARLISLE IA
50047-7685
US

V. Phone/Fax

Practice location:
  • Phone: 515-989-6008
  • Fax: 515-989-6008
Mailing address:
  • Phone: 515-989-6008
  • Fax: 515-989-6008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: