Provider Demographics
NPI:1033154836
Name:BOONE COUNTY FAMILY MEDICINE TR
Entity Type:Organization
Organization Name:BOONE COUNTY FAMILY MEDICINE TR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKAELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIENITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-432-3140
Mailing Address - Street 1:1115 S MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-5304
Mailing Address - Country:US
Mailing Address - Phone:515-432-2335
Mailing Address - Fax:515-432-2357
Practice Address - Street 1:1115 S MARSHALL ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-5304
Practice Address - Country:US
Practice Address - Phone:515-432-2335
Practice Address - Fax:515-432-2357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI6641Medicare PIN