Provider Demographics
NPI:1306965348
Name:LA CLINICA MEDICA LATINA OF DES MOINES LLC
Entity type:Organization
Organization Name:LA CLINICA MEDICA LATINA OF DES MOINES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OPERATIONS MGR CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:
Authorized Official - Last Name:EAGLES
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:515-265-8200
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:1300 DES MOINES ST
Practice Address - Street 2:SUITE 106
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-5502
Practice Address - Country:US
Practice Address - Phone:515-265-8200
Practice Address - Fax:515-262-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25966207R00000X
IAA098023363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADN6229OtherRAILROAD MEDICARE
IA0785931Medicaid
IA0785956Medicaid
IAS78713Medicare UPIN
IADN6229OtherRAILROAD MEDICARE