Provider Demographics
NPI:1013029081
Name:SWFAC PLC
Entity Type:Organization
Organization Name:SWFAC PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:C
Authorized Official - Last Name:STANISLAV
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:712-623-5178
Mailing Address - Street 1:502 E REED ST
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-2350
Mailing Address - Country:US
Mailing Address - Phone:712-623-5178
Mailing Address - Fax:
Practice Address - Street 1:502 E REED ST
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-2350
Practice Address - Country:US
Practice Address - Phone:712-623-5178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0429761Medicaid
IA0429761Medicaid
IA4643250001Medicare NSC