Healthcare Provider Details

I. General information

NPI: 1255339750
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 WEST AGENCY ROAD
WEST BURLINGTON IA
52655
US

IV. Provider business mailing address

1706 WEST AGENCY ROAD
WEST BURLINGTON IA
52655
US

V. Phone/Fax

Practice location:
  • Phone: 319-768-5858
  • Fax: 319-752-4653
Mailing address:
  • Phone: 319-768-5858
  • Fax: 319-752-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35097
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37355
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17758
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000671
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA045847
License Number StateIA

VIII. Authorized Official

Name: MR. ANTONIO FLORES
Title or Position: CEO
Credential: CEO
Phone: 319-768-5858