Provider Demographics
NPI:1083830236
Name:INFINITY HEALTH - ARCHIVED
Entity Type:Organization
Organization Name:INFINITY HEALTH - ARCHIVED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-446-2383
Mailing Address - Street 1:302 NE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LEON
Mailing Address - State:IA
Mailing Address - Zip Code:50144-1206
Mailing Address - Country:US
Mailing Address - Phone:641-446-2383
Mailing Address - Fax:641-446-2382
Practice Address - Street 1:802 ACKERLEY ST
Practice Address - Street 2:
Practice Address - City:LAMONI
Practice Address - State:IA
Practice Address - Zip Code:50140-1544
Practice Address - Country:US
Practice Address - Phone:641-784-7911
Practice Address - Fax:641-784-6162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA261QF0400X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
39015OtherWELLMARK BLUE CROSS/BLUE SHIELD
MO507202208Medicaid
IA0462861Medicaid
IA61827OtherWELLMARK MEDICARE BLUE PPO
IA0462861Medicaid
161827Medicare Oscar/Certification
IA61827OtherWELLMARK MEDICARE BLUE PPO