Provider Demographics
NPI:1386357432
Name:SEQUOIA MEDICAL SERVICES PLLC
Entity type:Organization
Organization Name:SEQUOIA MEDICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEPHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-579-1027
Mailing Address - Street 1:512 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:IA
Mailing Address - Zip Code:52216-9419
Mailing Address - Country:US
Mailing Address - Phone:814-243-0414
Mailing Address - Fax:
Practice Address - Street 1:770 TANGLEFOOT LN # 3256
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1608
Practice Address - Country:US
Practice Address - Phone:920-579-1027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-04
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA9999999999999Medicaid