1164631214 NPI number — NEW VENTURE GROUP HOME

Table of content: (NPI 1164631214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164631214 NPI number — NEW VENTURE GROUP HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW VENTURE GROUP HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164631214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 S WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORYDON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50060-1745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-872-1524
Provider Business Mailing Address Fax Number:
641-872-2843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 S WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORYDON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50060-1745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-872-1524
Provider Business Practice Location Address Fax Number:
641-872-2843
Provider Enumeration Date:
05/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MIDDLEBROOK
Authorized Official First Name:
MENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
TEMPORARY ADMINISTRATOR
Authorized Official Telephone Number:
641-872-1524

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  RMR-413 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2144725H , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0779733E , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1484676D , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0903780C , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0375474D , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".