Provider Demographics
NPI:1508882705
Name:MADRID FAMILY PRACTICE CLINIC
Entity Type:Organization
Organization Name:MADRID FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKAELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIENITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-432-3140
Mailing Address - Street 1:623 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-1023
Mailing Address - Country:US
Mailing Address - Phone:515-795-4300
Mailing Address - Fax:515-433-8905
Practice Address - Street 1:623 W NORTH ST
Practice Address - Street 2:
Practice Address - City:MADRID
Practice Address - State:IA
Practice Address - Zip Code:50156-1023
Practice Address - Country:US
Practice Address - Phone:515-795-4300
Practice Address - Fax:515-433-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA261QR1300X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
168574Medicare PIN
IAI11429Medicare PIN