Healthcare Provider Details

I. General information

NPI: 1750550653
Provider Name (Legal Business Name): KIRK C WHITTLESEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 TAFT ST S
HUMBOLDT IA
50548-2037
US

IV. Provider business mailing address

12 TAFT ST S
HUMBOLDT IA
50548-2037
US

V. Phone/Fax

Practice location:
  • Phone: 515-332-2950
  • Fax: 515-332-4451
Mailing address:
  • Phone: 515-332-2950
  • Fax: 515-332-4451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1581
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KIRK C WHITTLESEY
Title or Position: OWNER
Credential: OD
Phone: 515-332-2950