Healthcare Provider Details

I. General information

NPI: 1053369405
Provider Name (Legal Business Name): PELLA REGIONAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 MONROE ST
PELLA IA
50219-1189
US

IV. Provider business mailing address

405 MONROE ST
PELLA IA
50219-1189
US

V. Phone/Fax

Practice location:
  • Phone: 641-628-3832
  • Fax: 641-628-8894
Mailing address:
  • Phone: 641-628-3832
  • Fax: 641-628-8894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number630165H
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number630165H
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number630165H
License Number StateIA

VIII. Authorized Official

Name: ROBERT D KROESE
Title or Position: CEO
Credential:
Phone: 641-628-6604