Healthcare Provider Details

I. General information

NPI: 1194991109
Provider Name (Legal Business Name): DES MOINES PEDIATRIC & ADOLESCENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 BEAVER AVE
DES MOINES IA
50310-3903
US

IV. Provider business mailing address

2301 BEAVER AVE
DES MOINES IA
50310-3903
US

V. Phone/Fax

Practice location:
  • Phone: 515-255-3181
  • Fax: 515-255-9392
Mailing address:
  • Phone: 515-255-3181
  • Fax: 515-255-9392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROB FORNOFF
Title or Position: OWNER
Credential: M.D.
Phone: 515-255-3181