Provider Demographics
NPI:1750324612
Name:HAWARDEN REGIONAL HEALTHCARE CLINICS LLC
Entity Type:Organization
Organization Name:HAWARDEN REGIONAL HEALTHCARE CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:P
Authorized Official - Last Name:PULLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-551-3103
Mailing Address - Street 1:1122 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:HAWARDEN
Mailing Address - State:IA
Mailing Address - Zip Code:51023-1928
Mailing Address - Country:US
Mailing Address - Phone:712-551-3400
Mailing Address - Fax:712-551-2691
Practice Address - Street 1:1122 AVENUE L
Practice Address - Street 2:
Practice Address - City:HAWARDEN
Practice Address - State:IA
Practice Address - Zip Code:51023-1928
Practice Address - Country:US
Practice Address - Phone:712-551-3400
Practice Address - Fax:712-551-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1013955004Medicaid
IA0685032Medicaid
IA38497OtherWELLMARK BCBS IA GRP #
IA1013955004Medicaid
IA168503Medicare UPIN