1386780732 NPI number — DR. GWEN ANNE LOVELL KOLLATH DC

Table of content: DR. GWEN ANNE LOVELL KOLLATH DC (NPI 1386780732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386780732 NPI number — DR. GWEN ANNE LOVELL KOLLATH DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOVELL KOLLATH
Provider First Name:
GWEN
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1386780732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1612 NORTHWEST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50310-3850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-557-0315
Provider Business Mailing Address Fax Number:
515-267-5167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5460 MERLE HAY RD
Provider Second Line Business Practice Location Address:
STE G1
Provider Business Practice Location Address City Name:
JOHNSTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50131-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-276-5135
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2007

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: 111NX0800X , with the licence number:  06787 , 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)





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