Provider Demographics
NPI:1760916779
Name:MINE
Entity Type:Organization
Organization Name:MINE
Other - Org Name:SELF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MYSELF
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:FORKNER
Authorized Official - Suffix:III
Authorized Official - Credentials:UI
Authorized Official - Phone:515-729-9350
Mailing Address - Street 1:2 S.W. 9TH STREET
Mailing Address - Street 2:316
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1234
Mailing Address - Country:US
Mailing Address - Phone:515-729-9350
Mailing Address - Fax:
Practice Address - Street 1:2 SW 9TH ST
Practice Address - Street 2:316
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-4310
Practice Address - Country:US
Practice Address - Phone:515-729-9350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YTUKJTYKJT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA483062595302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA483062595Medicaid