Provider Demographics
NPI: | 1669470282 |
---|---|
Name: | A NEW IMAGE, INC. |
Entity type: | Organization |
Organization Name: | A NEW IMAGE, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BARBARA |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | DANIELS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 319-232-3219 |
Mailing Address - Street 1: | 1607 HEATH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | WATERLOO |
Mailing Address - State: | IA |
Mailing Address - Zip Code: | 50703-1930 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 319-232-3219 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1607 HEATH ST |
Practice Address - Street 2: | |
Practice Address - City: | WATERLOO |
Practice Address - State: | IA |
Practice Address - Zip Code: | 50703-1930 |
Practice Address - Country: | US |
Practice Address - Phone: | 319-232-3219 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-07-08 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IA | 0248278 | Medicaid | |
IA | 09017 | Other | IOWA BLUE CROSS BLUE SHIE |
IA | 0248278 | Medicaid |