MEDICARE: RENEE D LASS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	3589	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043228604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEE D LASS

Provider Business Mailing Address
First Line	:	4626 PROGRESS DR STE B
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52807-3485
Country	:	US
Telephone Number	:	563-359-3736
Fax Number	:	563-359-0153

Provider Business Practice Location Address
First Line	:	4626 PROGRESS DR STE B
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52807-3485
Country	:	US
Telephone Number	:	563-359-3736
Fax Number	:	563-359-0153

Authorized Official
Title or Position	:	OFFICE MGR
Name	:	PAM BELL
Credential	:
Telephone Number	:	563-359-3736

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	04/08/2008

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Directions to “RENEE D LASS ” Practice Location

Language	Start Address	Practice Location

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