Healthcare Provider Details

I. General information

NPI: 1881439701
Provider Name (Legal Business Name): MSGA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 KIMBALL AVE STE 130
WATERLOO IA
50701-9086
US

IV. Provider business mailing address

4150 KIMBALL AVE STE 130
WATERLOO IA
50701-9086
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-5390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN TORREZ
Title or Position: MANAGER, PRESIDENT
Credential:
Phone: 319-290-7456