Healthcare Provider Details

I. General information

NPI: 1013071422
Provider Name (Legal Business Name): ROBERT A FASBENDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 WEST 4TH STREET
CARROLL IA
51401-2715
US

IV. Provider business mailing address

215 WEST 4TH STREET
CARROLL IA
51401-2715
US

V. Phone/Fax

Practice location:
  • Phone: 712-792-3115
  • Fax: 712-792-3115
Mailing address:
  • Phone: 712-792-3115
  • Fax: 712-792-3115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT ANTHONY FASBENDER
Title or Position: OWNER SHOE & ORTHODIC FITTER
Credential:
Phone: 712-792-3115