Provider Demographics
NPI:1780141887
Name:GREAT RIVER PHYSICIANS AND CLINICS, INC
Entity type:Organization
Organization Name:GREAT RIVER PHYSICIANS AND CLINICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-768-3471
Mailing Address - Street 1:1221 S GEAR AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1679
Mailing Address - Country:US
Mailing Address - Phone:319-768-3471
Mailing Address - Fax:319-768-3266
Practice Address - Street 1:2750 MOUNT PLEASANT ST STE 104
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-2171
Practice Address - Country:US
Practice Address - Phone:319-752-7727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy