Provider Demographics
NPI:1417044645
Name:HEALTHY AGING AND MEMORY CLINIC
Entity Type:Organization
Organization Name:HEALTHY AGING AND MEMORY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:515-224-4100
Mailing Address - Street 1:2555 106TH STREET
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-3766
Mailing Address - Country:US
Mailing Address - Phone:515-334-7524
Mailing Address - Fax:515-334-7528
Practice Address - Street 1:1300 50TH STREET
Practice Address - Street 2:SUITE 104
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266
Practice Address - Country:US
Practice Address - Phone:515-224-4100
Practice Address - Fax:515-224-4926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QG0300X
IA22610207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2184259Medicaid
IA2184259Medicaid