Provider Demographics
NPI:1811310733
Name:TOWNLINE MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:TOWNLINE MEDICAL CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP-BC
Authorized Official - Phone:515-423-4685
Mailing Address - Street 1:1332 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAMONI
Mailing Address - State:IA
Mailing Address - Zip Code:50140-6311
Mailing Address - Country:US
Mailing Address - Phone:641-784-7526
Mailing Address - Fax:641-784-7527
Practice Address - Street 1:1332 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAMONI
Practice Address - State:IA
Practice Address - Zip Code:50140-6311
Practice Address - Country:US
Practice Address - Phone:641-784-7526
Practice Address - Fax:641-784-7526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA92500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1811310733Medicaid
IA1811310733OtherBCBS
IAIB3031Medicare UPIN