1295814234 NPI number — DEER CREEK HEALTH CENTER, LLC

Table of content: (NPI 1295814234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295814234 NPI number — DEER CREEK HEALTH CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEER CREEK HEALTH CENTER, LLC
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:
6
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:
1295814234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 1ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52342-2129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-484-2602
Provider Business Mailing Address Fax Number:
641-484-6837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52342-2129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-484-2602
Provider Business Practice Location Address Fax Number:
641-484-6837
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PROTEXTOR
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
319-337-7642

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0689224 . This is a "RHC MEDICAID" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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