Healthcare Provider Details

I. General information

NPI: 1487779575
Provider Name (Legal Business Name): THEODORE R. LIAUTAUD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E SHORE DR
LAKE VIEW IA
51450
US

IV. Provider business mailing address

PO BOX 710 421 E SHORE DR
LAKE VIEW IA
51450
US

V. Phone/Fax

Practice location:
  • Phone: 712-657-2211
  • Fax: 712-657-2106
Mailing address:
  • Phone: 712-657-2211
  • Fax: 712-657-2106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01790
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number01790
License Number StateIA

VIII. Authorized Official

Name: THEODORE R. LIAUTAUD
Title or Position: OWNER
Credential: DO
Phone: 712-657-2211