1558799031 NPI number — CCRC OF ALTOONA LLC

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 1558799031 NPI number — CCRC OF ALTOONA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCRC OF ALTOONA LLC
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:
6
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:
1558799031
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11827 W 112TH ST
Provider Second Line Business Mailing Address:
STE 103
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66210-2726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-890-4782
Provider Business Mailing Address Fax Number:
913-956-6564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2785 1ST AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTOONA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50009-8820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-967-8700
Provider Business Practice Location Address Fax Number:
515-967-6032
Provider Enumeration Date:
10/21/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GULLEDGE
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
913-890-4782

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0800115 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com