Healthcare Provider Details

I. General information

NPI: 1396726105
Provider Name (Legal Business Name): WILDA LEELLA OREWILER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 NE 2ND ST
STUART IA
50250
US

IV. Provider business mailing address

PO BOX 196
STUART IA
50250
US

V. Phone/Fax

Practice location:
  • Phone: 515-523-2283
  • Fax: 515-523-2786
Mailing address:
  • Phone: 515-523-2283
  • Fax: 515-523-2786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number000971
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: