Basic Information
| Provider Information | |||||||||
| NPI: | 1285627943 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PET CO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7147 VISTA DR STE 160 | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502669313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759924 | ||||||||
| FaxNumber: | 5158759923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 PLEASANT ST | ||||||||
| Address2: | STE 150A | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152445109 | ||||||||
| FaxNumber: | 5152413505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | C. | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5158759100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
No ID Information.