Provider Demographics
NPI:1407030513
Name:CHARLES J LATENDRESSE
Entity Type:Organization
Organization Name:CHARLES J LATENDRESSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:LATENDRESSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-824-3181
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:GRUNDY CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:50638-0128
Mailing Address - Country:US
Mailing Address - Phone:319-824-3181
Mailing Address - Fax:319-824-6680
Practice Address - Street 1:1506 G AVE
Practice Address - Street 2:
Practice Address - City:GRUNDY CENTER
Practice Address - State:IA
Practice Address - Zip Code:50638-1038
Practice Address - Country:US
Practice Address - Phone:319-824-3181
Practice Address - Fax:319-824-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty