Healthcare Provider Details

I. General information

NPI: 1831315415
Provider Name (Legal Business Name): MRS. SANDRA LOUISE DITTMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67464 250TH ST
COLO IA
50056-8614
US

IV. Provider business mailing address

67464 250TH ST
COLO IA
50056-8614
US

V. Phone/Fax

Practice location:
  • Phone: 641-377-2922
  • Fax:
Mailing address:
  • Phone: 641-377-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM3000X
TaxonomyMedically Fragile Infants and Children Day Care
License Number4285081
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: