1508162264 NPI number — MIDWEST PROPERTIES OF IDA GROVE L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508162264 NPI number — MIDWEST PROPERTIES OF IDA GROVE L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST PROPERTIES OF IDA GROVE L.L.C.
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:
GOLDEN HORIZONS OF IDA GROVE
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:
1508162264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 BYRON GODBERSEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDA GROVE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-364-4128
Provider Business Mailing Address Fax Number:
712-364-2002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 BYRON GODBERSEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDA GROVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-364-4128
Provider Business Practice Location Address Fax Number:
712-364-2002
Provider Enumeration Date:
01/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINETTE
Authorized Official First Name:
JEANA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
VICE PRESIDENT OF MANAGEMENT
Authorized Official Telephone Number:
218-568-6610

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  S0316 , 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)





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