Provider Demographics
NPI:1003013731
Name:FAMILY HEALTH CENTER OF WATERLOO, P.C.
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTER OF WATERLOO, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAKORNBUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-226-4400
Mailing Address - Street 1:220 W RIDGEWAY AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-4200
Mailing Address - Country:US
Mailing Address - Phone:319-226-4400
Mailing Address - Fax:319-226-4401
Practice Address - Street 1:220 W RIDGEWAY AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4200
Practice Address - Country:US
Practice Address - Phone:319-226-4400
Practice Address - Fax:319-226-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI15027Medicare ID - Type Unspecified