Healthcare Provider Details

I. General information

NPI: 1063465003
Provider Name (Legal Business Name): NORTHWEST IOWA UROLOGISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 1ST AVE E SUITE B
SPENCER IA
51301-4342
US

IV. Provider business mailing address

1200 1ST AVE E SUITE B
SPENCER IA
51301-4342
US

V. Phone/Fax

Practice location:
  • Phone: 712-262-6214
  • Fax: 712-262-6216
Mailing address:
  • Phone: 712-262-6214
  • Fax: 712-262-6216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number20168
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number24150
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number20168
License Number StateIA

VIII. Authorized Official

Name: DR. WALTER LESLIE MENDENHALL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 712-262-6214