1518214204 NPI number — LONG TERM CARE SERVICES PC

Table of content: (NPI 1518214204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518214204 NPI number — LONG TERM CARE SERVICES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONG TERM CARE SERVICES PC
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:
1518214204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2213 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50312-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-237-3974
Provider Business Mailing Address Fax Number:
515-883-2692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5927 HIGHLAND CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50266-2825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-327-2089
Provider Business Practice Location Address Fax Number:
515-440-4599
Provider Enumeration Date:
08/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
OVERTON
Authorized Official First Name:
ROY
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PHYSICIAN / PRESIDENT
Authorized Official Telephone Number:
515-327-2089

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  02075 , 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: IN PROCESS , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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