Healthcare Provider Details

I. General information

NPI: 1861551665
Provider Name (Legal Business Name): GARY VOLENTINE MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 HARMONY ST SUITE 404
COUNCIL BLUFFS IA
51503-3106
US

IV. Provider business mailing address

801 HARMONY ST SUITE 404
COUNCIL BLUFFS IA
51503-3106
US

V. Phone/Fax

Practice location:
  • Phone: 712-322-2332
  • Fax: 712-322-5122
Mailing address:
  • Phone: 712-322-2332
  • Fax: 712-322-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number21611
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number107489
License Number StateIA

VIII. Authorized Official

Name: MISS TAMMY K COLEGROVE
Title or Position: ARNP
Credential: ARNP
Phone: 712-322-2332