1215125513 NPI number — STACEY MEARDON

Table of content: STACEY MEARDON (NPI 1215125513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215125513 NPI number — STACEY MEARDON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEARDON
Provider First Name:
STACEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURKHARDT
Provider Other First Name:
STACEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215125513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1454 30TH ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
WEST DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50266-1305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-223-6620
Provider Business Mailing Address Fax Number:
515-223-9625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1454 30TH ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
WEST DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50266-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-223-6620
Provider Business Practice Location Address Fax Number:
515-223-9625
Provider Enumeration Date:
10/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  02969 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0665190 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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