Provider Demographics
NPI:1043452238
Name:PHYSICIANS LABORATORY OF NORTHWEST IOWA LTD
Entity Type:Organization
Organization Name:PHYSICIANS LABORATORY OF NORTHWEST IOWA LTD
Other - Org Name:PHYSICIANS LABORATORY OF NWIA
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7208
Mailing Address - Street 1:116 E 11TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4364
Mailing Address - Country:US
Mailing Address - Phone:712-262-3795
Mailing Address - Fax:712-262-3076
Practice Address - Street 1:116 E 11TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4364
Practice Address - Country:US
Practice Address - Phone:712-262-3795
Practice Address - Fax:712-262-3076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0073304Medicaid
IA0908822Medicaid
IAIB1644Medicare PIN
IA690004556Medicare PIN
IA01836Medicare PIN