Healthcare Provider Details

I. General information

NPI: 1306965348
Provider Name (Legal Business Name): LA CLINICA MEDICA LATINA OF DES MOINES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 DES MOINES ST SUITE 106
DES MOINES IA
50309-5502
US

IV. Provider business mailing address

2213 GRAND AVE
DES MOINES IA
50312-5305
US

V. Phone/Fax

Practice location:
  • Phone: 515-265-8200
  • Fax: 515-262-0045
Mailing address:
  • Phone: 515-237-3974
  • Fax: 515-883-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA098023
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25966
License Number StateIA

VIII. Authorized Official

Name: AVA EAGLES
Title or Position: CLINIC OPERATIONS MGR CO OWNER
Credential: ARNP
Phone: 515-265-8200