Provider Demographics
NPI:1316998289
Name:T L SPRAGUE DO PC
Entity type:Organization
Organization Name:T L SPRAGUE DO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PC
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SPRAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:712-563-4206
Mailing Address - Street 1:222 BROADWAY
Mailing Address - Street 2:AUDUBON MEDICAL CLINIC
Mailing Address - City:AUDUBON
Mailing Address - State:IA
Mailing Address - Zip Code:50025-1199
Mailing Address - Country:US
Mailing Address - Phone:712-563-4206
Mailing Address - Fax:712-563-2001
Practice Address - Street 1:222 BROADWAY
Practice Address - Street 2:AUDUBON MEDICAL CLINIC
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025-1199
Practice Address - Country:US
Practice Address - Phone:712-563-4206
Practice Address - Fax:712-563-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI3936OtherMEDICARE B GROUP #
IA0638536Medicaid
IA163853Medicare Oscar/Certification