1740283795 NPI number — EASTERN STAR MASONIC HOME

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:	EASTERN STAR MASONIC HOME
Provider Last Name (Legal Name)	:
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Provider Middle Name	:
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Provider Gender Code	:

Provider Other Organization Name	:
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Provider Other Last Name	:
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NPI Number	:	1740283795
Entity Type Code	:	Organization
Replacement NPI	:
Last Update Date	:	03/04/2008
NPI Deactivation Reason Code	:
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Provider First Line Business Mailing Address	:	715 W 3RD ST
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	BOONE
Provider Business Mailing Address State Name	:	IA
Provider Business Mailing Address Postal Code	:	500363930
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	5154325274
Provider Business Mailing Address Fax Number	:	5154325276

Provider First Line Business Practice Location Address	:	715 W 3RD ST
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	BOONE
Provider Business Practice Location Address State Name	:	IA
Provider Business Practice Location Address Postal Code	:	500363930
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	5154325274
Provider Business Practice Location Address Fax Number	:	5154325276
Provider Enumeration Date	:	05/23/2005

Authorized Official Last Name	:	BOCK
Authorized Official First Name	:	DENNIS
Authorized Official Middle Name	:	A.
Authorized Official Title or Position	:	ADMINISTRATOR
Authorized Official Telephone Number	:	5154325274

• Taxonomy code: 314000000X , with the licence number:  N-0268 , registered in the state of IA .
• Taxonomy code: 311Z00000X , with the licence number: R-268 , registered in the state of IA .
• Taxonomy code: 313M00000X , with the licence number: N-0268 , registered in the state of IA .

• Identifier: 16-5468 , issued by the state of ( IA ) . This identifiers is of the category "".
• Identifier: 0890210 , issued by the state of ( IA ) . This identifiers is of the category "".
• Identifier: 165468 , issued by the state of ( IA ) . This identifiers is of the category "".
• Identifier: 0801076 , issued by the state of ( IA ) . This identifiers is of the category "".