=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164702239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFORDABLE MEDICAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2011
-----------------------------------------------------
Last Update Date | 08/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2827 HAMILTON BLVD
-----------------------------------------------------
City | SIOUX CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51104-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-258-4350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2495
-----------------------------------------------------
City | SIOUX CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51106-0495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-258-4350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOHN DANIELS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 712-258-4350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 088583
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------