1760698039 NPI number — PRAIRIE HILLS MANAGEMENT LLC

Table of content: CAROLINE DJAMBOU (NPI 1497459531)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760698039 NPI number — PRAIRIE HILLS MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE HILLS MANAGEMENT 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:
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:
1760698039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 N 3RD ST
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52556-2485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-472-0518
Provider Business Mailing Address Fax Number:
641-472-0817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 ENTERPRISE DR SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50644-9603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-334-2000
Provider Business Practice Location Address Fax Number:
319-334-3015
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HILDEBRANDT
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
641-472-0518

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0483594 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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