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General NPI Number Information
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NPI Number | 1457600157
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Entity Type | Organization
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Legal Business Name | AEON GROUP HST
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Dates
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Enumeration Date | 09/10/2012
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Last Update Date | 09/10/2012
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Provider Practice Location Address
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Address Line | 1801 E 54TH ST SUITE 200
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City | DAVENPORT
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State | IA
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Zip | 52807-7209
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Country | US
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Telephone | 563-386-1904
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Fax | 866-899-2592
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Provider Business Mailing Address
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Address Line | 1801 E 54TH ST SUITE 200
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City | DAVENPORT
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State | IA
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Zip | 52807-7209
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Country | US
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Telephone | 563-386-1904
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Fax | 866-899-2592
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Authorized Official
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Title or Position | PROJECT MANAGER
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Name | PENNY T GRUNDER
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Credential |
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Telephone | 563-386-1904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State | IA
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