Provider Demographics
NPI:1740579101
Name:POLK COUNTY
Entity Type:Organization
Organization Name:POLK COUNTY
Other - Org Name:POLK COUNTY HEALTH DEPARTMENT - FAMILY PRACTICE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOZIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-286-3798
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:1907 CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1310
Practice Address - Country:US
Practice Address - Phone:515-286-3798
Practice Address - Fax:515-286-2033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1740279101Medicaid
IA1740579101OtherBCBS
IAIB2210Medicare PIN