Provider Demographics
NPI:1255339750
Name:COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC
Entity type:Organization
Organization Name:COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:319-768-5858
Mailing Address - Street 1:1706 WEST AGENCY ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655
Mailing Address - Country:US
Mailing Address - Phone:319-768-5858
Mailing Address - Fax:319-752-4653
Practice Address - Street 1:1706 WEST AGENCY ROAD
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655
Practice Address - Country:US
Practice Address - Phone:319-768-5858
Practice Address - Fax:319-752-4653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000671363A00000X
IAA045847363L00000X
IA17758208000000X
IA35097207R00000X
IA37355207R00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0288175Medicaid
IA35732OtherBC/BS OF IOWA
MO506089432Medicaid
IA35732OtherBC/BS OF IOWA
IA161819Medicare Oscar/Certification
MO506089432Medicaid