1174519532 NPI number — HEARTLAND CARE CENTER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174519532 NPI number — HEARTLAND CARE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND 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:
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:
1174519532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 E FENTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARCUS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51035-7170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-376-2500
Provider Business Mailing Address Fax Number:
712-376-4445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 E FENTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARCUS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51035-7170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-376-2500
Provider Business Practice Location Address Fax Number:
712-376-4445
Provider Enumeration Date:
09/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROGGE
Authorized Official First Name:
LUANN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
712-376-2500

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  S0014 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 180689 , 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: 0809020 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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