=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487080297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AEGIS THERAPIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2013
-----------------------------------------------------
Last Update Date | 09/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 819 COUNTRY LANE RD
-----------------------------------------------------
City | KEOSAUQUA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52565-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-293-3761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1433 SILVERWOOD LN
-----------------------------------------------------
City | OTTUMWA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52501-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-814-2275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COTA
-----------------------------------------------------
Name | JOHN KEVIN LARKIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 641-814-2275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 000953
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------