Provider Demographics
NPI:1578803599
Name:HUMBOLDT SPINE & REHAB PC
Entity Type:Organization
Organization Name:HUMBOLDT SPINE & REHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CIRKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:515-368-0086
Mailing Address - Street 1:1146 190TH ST
Mailing Address - Street 2:
Mailing Address - City:BRADGATE
Mailing Address - State:IA
Mailing Address - Zip Code:50520-8710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 6TH AVE N
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:IA
Practice Address - Zip Code:50548-1102
Practice Address - Country:US
Practice Address - Phone:515-368-0086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007613261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care