1316152564 NPI number — PRAIRIE HILLS AT CLINTON OPERATIONS LLC

Table of content: (NPI 1316152564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316152564 NPI number — PRAIRIE HILLS AT CLINTON OPERATIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE HILLS AT CLINTON OPERATIONS 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:
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:
1316152564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 N 3RD ST
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52556-2485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-472-0518
Provider Business Mailing Address Fax Number:
641-472-0817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 13TH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52732-3341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-243-6870
Provider Business Practice Location Address Fax Number:
563-242-0404
Provider Enumeration Date:
05/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HILDEBRANDT
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
641-472-0518

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0733121 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".