Healthcare Provider Details

I. General information

NPI: 1962618355
Provider Name (Legal Business Name): SAC & FOX OF THE MISS IN IOWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1646 305TH STREET STE A
TAMA IA
52339-9634
US

IV. Provider business mailing address

1646 305TH STREET
TAMA IA
52339-9634
US

V. Phone/Fax

Practice location:
  • Phone: 641-484-4094
  • Fax: 641-484-2432
Mailing address:
  • Phone: 641-484-4094
  • Fax: 641-484-2432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIRZA GONZALES
Title or Position: DIRECTOR ADMINISTRATIVE SERVICES
Credential:
Phone: 641-484-4094