Healthcare Provider Details

I. General information

NPI: 1407030513
Provider Name (Legal Business Name): CHARLES J LATENDRESSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 G AVE
GRUNDY CENTER IA
50638-1038
US

IV. Provider business mailing address

PO BOX 128
GRUNDY CENTER IA
50638-0128
US

V. Phone/Fax

Practice location:
  • Phone: 319-824-3181
  • Fax: 319-824-6680
Mailing address:
  • Phone: 319-824-3181
  • Fax: 319-824-6680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES J LATENDRESSE
Title or Position: OWNER
Credential: MD
Phone: 319-824-3181