Provider Demographics
NPI:1043228604
Name:RENEE D LASS
Entity Type:Organization
Organization Name:RENEE D LASS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-359-3736
Mailing Address - Street 1:4626 PROGRESS DR STE B
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3485
Mailing Address - Country:US
Mailing Address - Phone:563-359-3736
Mailing Address - Fax:563-359-0153
Practice Address - Street 1:4626 PROGRESS DR STE B
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3485
Practice Address - Country:US
Practice Address - Phone:563-359-3736
Practice Address - Fax:563-359-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3444885Medicaid
IAPIN NUMBERMedicare ID - Type UnspecifiedI16823
IA3444885Medicaid
IAGROUP NUMBERMedicare ID - Type UnspecifiedI16832