Healthcare Provider Details

I. General information

NPI: 1619009297
Provider Name (Legal Business Name): JEAN ANCIAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 1ST STREET A
MOLINE IL
61265-7728
US

IV. Provider business mailing address

4722 TORREY PINES CT
DAVENPORT IA
52807-3301
US

V. Phone/Fax

Practice location:
  • Phone: 309-797-9286
  • Fax: 309-797-0199
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: