=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952363608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IOWA LAKES ORTHOPAEDICS , P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2006
-----------------------------------------------------
Last Update Date | 09/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2309 23RD ST.
-----------------------------------------------------
City | SPIRIT LAKE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51360-0273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-336-5311
-----------------------------------------------------
Fax | 712-336-0020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2309 23RD ST. P. O. BOX 273
-----------------------------------------------------
City | SPIRIT LAKE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51360-0273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-336-5311
-----------------------------------------------------
Fax | 712-336-0020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC ADMINISTRATOR
-----------------------------------------------------
Name | MR. GREGORY SHELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 712-336-5311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------