Healthcare Provider Details

I. General information

NPI: 1750468930
Provider Name (Legal Business Name): OLYMPIA NIEDERECKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 1ST AVE NE
CEDAR RAPIDS IA
52402-5431
US

IV. Provider business mailing address

923 HARLOCKE ST
IOWA CITY IA
52246-5127
US

V. Phone/Fax

Practice location:
  • Phone: 319-362-3937
  • Fax: 319-362-2900
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier0380170001
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerDMERC
# 2
Identifier13625
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBCBS
# 3
Identifier0136259
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: