Provider Demographics
NPI:1811076565
Name:CITY OF WATERLOO
Entity type:Organization
Organization Name:CITY OF WATERLOO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-291-4279
Mailing Address - Street 1:425 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-3511
Mailing Address - Country:US
Mailing Address - Phone:319-291-4279
Mailing Address - Fax:888-965-4620
Practice Address - Street 1:425 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-3511
Practice Address - Country:US
Practice Address - Phone:319-291-4460
Practice Address - Fax:319-291-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3416L0300X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0090217Medicaid
IA0090217Medicaid
IA09021Medicare PIN