Healthcare Provider Details

I. General information

NPI: 1568009538
Provider Name (Legal Business Name): JAVIC AVIATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 LAFAYETTE AVE
STORY CITY IA
50248-1454
US

IV. Provider business mailing address

1106 KAMEN DR
WEBSTER CITY IA
50595-3501
US

V. Phone/Fax

Practice location:
  • Phone: 515-733-4325
  • Fax:
Mailing address:
  • Phone: 515-297-4708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL JAMES BOEKE
Title or Position: MANAGING MEMBER
Credential: MBA
Phone: 515-297-4708