Organization
MINE
Active
Parent organization
YTUKJTYKJT
Other names
SELF
Organization subpart
Yes
Provider details
NPI number
Legal business name
YTUKJTYKJT
Authorized official
MR. ROBERT DEAN FORKNER III UI (MYSELF)
(515) 729-9350
Entity
Organization
Contact information
Practice address
2 SW 9TH ST, 316, DES MOINES, IA 50309-4310
(515) 729-9350
Mailing address
2 S.W. 9TH STREET, 316, DES MOINES, IA 50309-1234
(515) 729-9350
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
Primary
483062595
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
483062595
—
IA
Enumeration date
04/17/2017
Last updated
04/17/2017
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