1740246883 NPI number — HAWKEYE CARE CENTER OF CRESCO LLC

Table of content: (NPI 1740246883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740246883 NPI number — HAWKEYE CARE CENTER OF CRESCO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAWKEYE CARE CENTER OF CRESCO 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:
HAWKEYE CARE CENTER CRESCO
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:
1740246883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1912 ZENITH AVE
Provider Second Line Business Mailing Address:
SUITE 2526
Provider Business Mailing Address City Name:
SPIRIT LAKE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51360-1000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-759-1321
Provider Business Mailing Address Fax Number:
712-759-1322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 VERNON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESCO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52136-1944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-547-3580
Provider Business Practice Location Address Fax Number:
563-547-3532
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
DOUG
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
515-223-0173

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  450905 , 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: 0809467 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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