1699768630 NPI number — COMMUNITY CARE CENTER INC

Table of content: (NPI 1699768630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699768630 NPI number — COMMUNITY CARE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY CARE CENTER INC
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:
COMMUNITY CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1699768630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 SW 7TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50250-2098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-523-2815
Provider Business Mailing Address Fax Number:
515-523-9123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 SW 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50250-2098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-523-2815
Provider Business Practice Location Address Fax Number:
515-523-9123
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JANSSEN
Authorized Official First Name:
MARADITH
Authorized Official Middle Name:
ANETTE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
515-523-2815

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0800813 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0147108 . This is a "ELDERLY WAIVER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com