1780686220 NPI number — MIDLANDS LIVING CENTER, L.L.P.

Table of content: MRS. AMY LOUISE SMITH RD LD (NPI 1316161805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780686220 NPI number — MIDLANDS LIVING CENTER, L.L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDLANDS LIVING CENTER, L.L.P.
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:
1780686220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2452 N BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COUNCIL BLUFFS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51503-0432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-323-7135
Provider Business Mailing Address Fax Number:
712-325-0289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2452 N BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-0434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-323-7135
Provider Business Practice Location Address Fax Number:
712-325-0289
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
712-323-7135

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  780508 , 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: 0809582 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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