Provider Demographics
NPI:1962934877
Name:PRUCHNO MEDICINE LLC. / HEALTH TRANSITIONS CLINIC
Entity type:Organization
Organization Name:PRUCHNO MEDICINE LLC. / HEALTH TRANSITIONS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-247-3894
Mailing Address - Street 1:202 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2414
Mailing Address - Country:US
Mailing Address - Phone:319-247-3894
Mailing Address - Fax:
Practice Address - Street 1:202 10TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2414
Practice Address - Country:US
Practice Address - Phone:319-247-3894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079549132700000X, 133V00000X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Single Specialty
No132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1101865Medicaid
IA1101865Medicaid