Healthcare Provider Details

I. General information

NPI: 1740232842
Provider Name (Legal Business Name): CRESTON MEDICAL CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 W TOWNLINE ST SUITE 200
CRESTON IA
50801-1066
US

IV. Provider business mailing address

1610 W TOWNLINE ST SUITE 200
CRESTON IA
50801-1066
US

V. Phone/Fax

Practice location:
  • Phone: 641-782-2131
  • Fax: 641-782-6425
Mailing address:
  • Phone: 641-782-2131
  • Fax: 641-782-6425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES E MANSOUR
Title or Position: PRESIDENT OF THE CORPORATION
Credential: M.D.
Phone: 641-782-2131