Healthcare Provider Details

I. General information

NPI: 1932825197
Provider Name (Legal Business Name): AMBER BORDOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 FAYETTE ST
CLINTON IA
52732-7111
US

IV. Provider business mailing address

145 FAYETTE ST
CLINTON IA
52732-7111
US

V. Phone/Fax

Practice location:
  • Phone: 563-241-2969
  • Fax:
Mailing address:
  • Phone: 563-241-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number800ZZ2764
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: