Provider Demographics
NPI:1750550653
Name:KIRK C WHITTLESEY
Entity type:Organization
Organization Name:KIRK C WHITTLESEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITTLESEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-332-2950
Mailing Address - Street 1:12 TAFT ST S
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:IA
Mailing Address - Zip Code:50548-2037
Mailing Address - Country:US
Mailing Address - Phone:515-332-2950
Mailing Address - Fax:515-332-4451
Practice Address - Street 1:12 TAFT ST S
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:IA
Practice Address - Zip Code:50548-2037
Practice Address - Country:US
Practice Address - Phone:515-332-2950
Practice Address - Fax:515-332-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1581332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0239040001Medicare NSC