Healthcare Provider Details

I. General information

NPI: 1508882705
Provider Name (Legal Business Name): MADRID FAMILY PRACTICE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 W NORTH ST
MADRID IA
50156-1023
US

IV. Provider business mailing address

623 W NORTH ST
MADRID IA
50156-1023
US

V. Phone/Fax

Practice location:
  • Phone: 515-795-4300
  • Fax: 515-433-8905
Mailing address:
  • Phone: 515-795-4300
  • Fax: 515-433-8905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MIKAELA KIENITZ
Title or Position: CEO
Credential:
Phone: 515-432-3140