Healthcare Provider Details

I. General information

NPI: 1649707977
Provider Name (Legal Business Name): BRIAN WORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 05/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E STATE ST
CENTERVILLE IA
52544-1813
US

IV. Provider business mailing address

302 NE 14TH ST
LEON IA
50144-1206
US

V. Phone/Fax

Practice location:
  • Phone: 641-856-6471
  • Fax: 641-856-2779
Mailing address:
  • Phone: 641-446-2383
  • Fax: 641-446-2382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: