Provider Demographics
NPI:1457742587
Name:WEST BROADWAY CLINIC, P.C.
Entity Type:Organization
Organization Name:WEST BROADWAY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:N
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:712-256-5600
Mailing Address - Street 1:1701 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3822
Mailing Address - Country:US
Mailing Address - Phone:712-256-5600
Mailing Address - Fax:712-256-3440
Practice Address - Street 1:1701 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3822
Practice Address - Country:US
Practice Address - Phone:712-256-5600
Practice Address - Fax:712-256-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA076849363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty