1962546374 NPI number — CHILDSERVE HABILITATION CENTER

Table of content: (NPI 1962546374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962546374 NPI number — CHILDSERVE HABILITATION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDSERVE HABILITATION CENTER
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:
1962546374
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:
PO BOX 707
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50131-0707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-727-8750
Provider Business Mailing Address Fax Number:
515-727-8757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5900 PIONEER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50131-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-270-2205
Provider Business Practice Location Address Fax Number:
515-276-0140
Provider Enumeration Date:
02/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILDRICK
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF ACCOUNTING
Authorized Official Telephone Number:
515-727-1468

Provider Taxonomy Codes

  • Taxonomy code: 3140N1450X , with the licence number:  770916 , 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: 0659938 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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