Healthcare Provider Details

I. General information

NPI: 1922279439
Provider Name (Legal Business Name): PREVENTATIVE HEALTH CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 BERKSHIRE PKWY
CLIVE IA
50325-4678
US

IV. Provider business mailing address

2213 GRAND AVE
DES MOINES IA
50312-5305
US

V. Phone/Fax

Practice location:
  • Phone: 515-225-2578
  • Fax: 515-225-2598
Mailing address:
  • Phone: 515-237-3974
  • Fax: 515-883-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number007026
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03475
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001132
License Number StateIA

VIII. Authorized Official

Name: ANGELIA RENEE WHETRO
Title or Position: MED DIRECTOR
Credential: DO
Phone: 515-225-2578