=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093221038
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAF INDUSTRIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2017
-----------------------------------------------------
Last Update Date | 12/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3345 HILLCREST RD
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52002-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-556-0755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3345 HILLCREST RD
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52002-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-556-0755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. KELLIE JOANN HANCOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 563-556-0755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------