Healthcare Provider Details

I. General information

NPI: 1386665461
Provider Name (Legal Business Name): FAMILY & SPECIALTY MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N MAIN ST
CARROLL IA
51401-2739
US

IV. Provider business mailing address

515 N MAIN ST
CARROLL IA
51401-2739
US

V. Phone/Fax

Practice location:
  • Phone: 712-792-4000
  • Fax: 712-792-7773
Mailing address:
  • Phone: 712-792-4000
  • Fax: 712-792-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000745
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3267
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02754
License Number StateIA

VIII. Authorized Official

Name: DANETTE M FOX
Title or Position: CREDENTIALING
Credential:
Phone: 712-792-4000