1174582985 NPI number — CARDINAL CARE CORP

Table of content: (NPI 1174582985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174582985 NPI number — CARDINAL CARE CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDINAL CARE CORP
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:
DANVILLE CARE CENTER
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:
1174582985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 S 31ST ST STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEOKUK
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52632-2264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-524-2029
Provider Business Mailing Address Fax Number:
319-524-2046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 S BIRCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52623-9613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-392-4259
Provider Business Practice Location Address Fax Number:
319-392-4078
Provider Enumeration Date:
03/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
MARC
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
217-440-9588

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  290870 , 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: 16D0691717 . This is a "CLIA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0805606 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".