Provider Demographics
NPI:1922279439
Name:PREVENTATIVE HEALTH CLINIC INC
Entity Type:Organization
Organization Name:PREVENTATIVE HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MED DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WHETRO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:515-225-2578
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 1:2480 BERKSHIRE PKWY
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-4678
Practice Address - Country:US
Practice Address - Phone:515-225-2578
Practice Address - Fax:515-225-2598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007026111N00000X
IA03475207Q00000X
IA001132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1077Medicare PIN
IAH98745Medicare UPIN