Healthcare Provider Details

I. General information

NPI: 1164854279
Provider Name (Legal Business Name): TIMOTHY RERUCHA-MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 HICKMAN RD
DES MOINES IA
50314-1505
US

IV. Provider business mailing address

1801 HICKMAN RD
DES MOINES IA
50314-1505
US

V. Phone/Fax

Practice location:
  • Phone: 515-282-5730
  • Fax:
Mailing address:
  • Phone: 515-282-5730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number007738
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: