Healthcare Provider Details

I. General information

NPI: 1639611361
Provider Name (Legal Business Name): DOUGLAS DIMIG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 LAUREL ST
DES MOINES IA
50314-3045
US

IV. Provider business mailing address

450 LAUREL ST
DES MOINES IA
50314-3045
US

V. Phone/Fax

Practice location:
  • Phone: 515-323-6485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001221
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: