Provider Demographics
NPI:1265480040
Name:DISTAFF PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:DISTAFF PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLINE-CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:641-664-3621
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52537-0067
Mailing Address - Country:US
Mailing Address - Phone:641-664-3621
Mailing Address - Fax:641-664-3690
Practice Address - Street 1:607 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:IA
Practice Address - Zip Code:52537-1516
Practice Address - Country:US
Practice Address - Phone:641-664-3621
Practice Address - Fax:641-664-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I3145Medicare ID - Type Unspecified