Provider Demographics
NPI:1013071422
Name:ROBERT A FASBENDER
Entity type:Organization
Organization Name:ROBERT A FASBENDER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER SHOE & ORTHODIC FITTER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:FASBENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-792-3115
Mailing Address - Street 1:215 WEST 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-2715
Mailing Address - Country:US
Mailing Address - Phone:712-792-3115
Mailing Address - Fax:712-792-3115
Practice Address - Street 1:215 WEST 4TH STREET
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-2715
Practice Address - Country:US
Practice Address - Phone:712-792-3115
Practice Address - Fax:712-792-3115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0034538Medicaid