=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497984579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROTEUS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2009
-----------------------------------------------------
Last Update Date | 05/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1221 CENTER ST STE 16
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50309-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-271-5303
-----------------------------------------------------
Fax | 515-271-5309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1221 CENTER ST STE 16
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50309-1014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-271-5306
-----------------------------------------------------
Fax | 515-271-5309
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JESUS SOTO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-348-6646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1000X
-----------------------------------------------------
Taxonomy Name | Migrant Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------