Provider Demographics
NPI:1861516452
Name:COUNTY OF BLACKHAWK
Entity type:Organization
Organization Name:COUNTY OF BLACKHAWK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NAFISSA
Authorized Official - Middle Name:CISSE
Authorized Official - Last Name:EGBUONYE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:319-291-2413
Mailing Address - Street 1:1407 INDEPENDENCE AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-4396
Mailing Address - Country:US
Mailing Address - Phone:319-291-2413
Mailing Address - Fax:319-291-2418
Practice Address - Street 1:1407 INDEPENDENCE AVE FL 5
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-4396
Practice Address - Country:US
Practice Address - Phone:319-291-2413
Practice Address - Fax:319-291-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2019-05-30
Deactivation Date:2019-02-05
Deactivation Code:
Reactivation Date:2019-05-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13516Medicare ID - Type UnspecifiedFLU