Provider Demographics
NPI:1356788780
Name:IDA GROVE FAMILY HEALTH CENTER, PLLC
Entity type:Organization
Organization Name:IDA GROVE FAMILY HEALTH CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:LUFT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:712-364-2300
Mailing Address - Street 1:101 2ND ST
Mailing Address - Street 2:
Mailing Address - City:IDA GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:51445-1401
Mailing Address - Country:US
Mailing Address - Phone:712-364-2300
Mailing Address - Fax:712-364-2881
Practice Address - Street 1:2540 N AVE
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:IA
Practice Address - Zip Code:51442-7584
Practice Address - Country:US
Practice Address - Phone:712-364-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDA GROVE FAMILY HEALTH CENTER, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-24
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03156261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care